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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Increased sweating: This is incorrect. Increased sweating is not typically indicative of internal hemorrhaging. It can be associated with various conditions but is not a specific sign of internal bleeding.
B. Increased redness at the site: This is incorrect. Increased redness would more likely be associated with localized infection or inflammation rather than internal hemorrhaging.
C. Increased abdominal distention: This is correct. Increased abdominal distention can be a sign of internal hemorrhaging, particularly if blood accumulates in the abdominal cavity (hemoperitoneum), leading to abdominal swelling and discomfort.
D. Increased blood pressure: This is incorrect. Internal hemorrhaging often leads to hypotension rather than increased blood pressure, as blood volume decreases and the body attempts to compensate.
Correct Answer is B
Explanation
A. Pantoprazole: This medication is a proton pump inhibitor used to treat acid-related disorders and does not interact adversely with sildenafil.
B. Isosorbide mononitrate: This is correct. Isosorbide mononitrate is a nitrate used to treat angina. Combining it with sildenafil can lead to severe hypotension due to their additive vasodilatory effects.
C. Acetylsalicylic acid: This is incorrect. Acetylsalicylic acid (aspirin) is used for pain relief and cardiovascular protection and does not contraindicate sildenafil use.
D. Atorvastatin sodium: This is incorrect. Atorvastatin is a statin used to manage cholesterol levels and does not contraindicate sildenafil use.
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