A nurse working in an emergency department is caring for a client who has third-degree frostbite to both lower extremities. The nurse should take which of the following actions?

Massage the legs.

Apply dry heat to the legs.

Elevate the legs.

Immerse the legs in cold water.

Answer and Explanation

The Correct Answer is C

A. Massage the legs: This is incorrect. Massage is contraindicated as it can cause further tissue damage and is not appropriate for frostbite.
B. Apply dry heat to the legs: This is incorrect. Dry heat can exacerbate tissue damage. Rewarming should be done using controlled, warm water immersion, not dry heat.
C. Elevate the legs: This is correct. Elevating the legs helps reduce swelling and can prevent further tissue damage. However, rewarming should be done carefully in a controlled environment.
D. Immerse the legs in cold water: This is incorrect. Immersing in cold water would worsen the frostbite. Rewarming should be done using warm (not hot) water, ideally at 37-39°C (98.6-102.2°F), for effective treatment.

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Correct Answer is C

Explanation

A. Ensure the client's intake is greater than their output: This is incorrect. In continuous bladder irrigation, the output may exceed the intake because the irrigation fluid is used to flush the bladder. The focus should be on ensuring proper drainage and monitoring for clots or obstruction rather than ensuring intake exceeds output.
B. Monitor the client's urine output every eight hours: This is incorrect. Following a transurethral resection of the prostate with continuous bladder irrigation, urine output should be monitored more frequently to ensure the irrigation system is functioning properly and to assess for signs of bleeding or obstruction.
C. Remind the client he might feel a constant urge to void: This is correct. It is common for clients to experience a constant urge to void due to bladder irritation and the presence of the catheter.
D. Assess for manifestations of fluid volume deficiency: This is incorrect. The primary concern with continuous bladder irrigation is monitoring for signs of bleeding or obstruction rather than fluid volume deficiency. Fluid balance is monitored based on intake and output, but deficiency is less likely in this context.

A. A client who has an open upper extremity fracture B. A client experiencing a tension pneumothorax C. A client who has full-thickness burns over 85% of their body D. A client who has agonal respirations

Correct Answer is B

Explanation

A. A client who has an open upper extremity fracture: While this is a serious injury, it is less critical compared to a tension pneumothorax in a triage setting.
B. A client experiencing a tension pneumothorax: This is a life-threatening condition that requires immediate intervention to relieve pressure on the lungs and restore adequate breathing.
C. A client who has full-thickness burns over 85% of their body: This is a severe condition with a high mortality risk, but in a mass casualty situation, a tension pneumothorax is prioritized for immediate care.
D. A client who has agonal respirations: Agonal respirations indicate severe distress, but the immediate need for intervention is to address conditions that can rapidly compromise life, such as a tension pneumothorax.

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A nurse working in an emergency department is caring for a client who has third-degree frostbite to both lower extremities. The nurse should take which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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