A nurse is teaching a client who has a new second-degree ankle sprain. Which of the following instructions should the nurse include in the teaching? Select all that apply.
Apply intermittent ice to the affected ankle for the first 48 hours.
Wrap the affected ankle with an elasticized compression bandage.
Apply full weight-bearing on the affected ankle.
Elevate the affected ankle above the level of the heart.
Apply a heating pad intermittently to the affected ankle after 48 hours.
Correct Answer : A,B,D,E
Choice A reason: Apply intermittent ice to the affected ankle for the first 48 hours
Applying ice intermittently to the affected ankle for the first 48 hours helps reduce swelling and inflammation. Ice should be applied for 15-20 minutes every 2-3 hours during the initial phase of injury management. This practice is part of the RICE (Rest, Ice, Compression, Elevation) protocol commonly used for sprains and strains.
Choice B reason: Wrap the affected ankle with an elasticized compression bandage
Wrapping the affected ankle with an elasticized compression bandage helps to minimize swelling and provide support to the injured area. Compression bandages should be snug but not too tight to avoid restricting blood flow. This is another component of the RICE protocol.
Choice C reason: Apply full weight-bearing on the affected ankle
Applying full weight-bearing on the affected ankle is not recommended immediately after a second-degree sprain. The ankle needs time to heal, and weight-bearing should be gradually reintroduced as pain and swelling decrease. Initially, the client should avoid putting weight on the injured ankle to prevent further damage.
Choice D reason: Elevate the affected ankle above the level of the heart
Elevating the affected ankle above the level of the heart helps reduce swelling by promoting venous return and decreasing fluid accumulation in the injured area. This is an essential part of the RICE protocol and should be done as much as possible during the first 48 hours.
Choice E reason: Apply a heating pad intermittently to the affected ankle after 48 hours
Applying a heating pad intermittently to the affected ankle after 48 hours can help increase blood flow and promote healing. Heat therapy should be used after the initial acute phase (first 48 hours) when swelling has subsided. Heat can help relax muscles and reduce stiffness in the injured area.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Withhold oral fluids and food
Withholding oral fluids and food (NPO status) is a critical intervention for clients with acute pancreatitis. This helps to rest the pancreas by reducing the stimulation of pancreatic enzyme secretion, which can exacerbate inflammation and pain. Maintaining NPO status is essential to prevent further pancreatic damage and to allow the pancreas to heal.
Choice B reason: Auscultate the client’s lungs
While auscultating the lungs is an important part of the overall assessment, it is not the immediate priority after pain management in acute pancreatitis. Respiratory complications can occur, but the primary focus should be on managing the pancreatic inflammation and preventing further damage.
Choice C reason: Provide oral hygiene
Providing oral hygiene is important for overall patient care, especially when the client is NPO. However, it is not the priority intervention immediately after pain management. The primary concern is to prevent further pancreatic stimulation and manage the inflammation.
Choice D reason: Assist the client to a side-lying position
Assisting the client to a side-lying position can help with comfort and may be beneficial in managing pain. However, it is not the priority intervention. The main focus should be on preventing further pancreatic stimulation by withholding oral intake.
Correct Answer is D
Explanation
Choice A reason: Reinforce discharge teaching to clients
While reinforcing discharge teaching is important, it is not the immediate priority during a disaster situation with limited staff. The focus should be on addressing urgent and life-threatening needs first. Discharge teaching can be addressed once the immediate crisis is managed and resources are more available.
Choice B reason: Instruct the assistive personnel (AP) to focus on clients’ ADLs
Instructing assistive personnel to focus on clients’ activities of daily living (ADLs) is important for maintaining basic care, but it is not the highest priority in a disaster situation. The primary focus should be on preventing life-threatening emergencies and ensuring the safety of all clients.
Choice C reason: Stock additional unit supplies
Stocking additional unit supplies is a proactive measure, but it is not the immediate priority during a disaster with limited staff. Ensuring that clients are safe and that life-threatening emergencies are prevented takes precedence over restocking supplies.
Choice D reason: Focus on providing care that prevents life-threatening emergencies
Focusing on providing care that prevents life-threatening emergencies is the highest priority in a disaster situation. With limited staff, it is crucial to prioritize interventions that ensure the immediate safety and well-being of clients. This includes monitoring for and addressing any critical changes in clients’ conditions and providing necessary emergency care.
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