A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?
Ask the patient to try bearing weight on the ankle
Elevate the ankle above heart level
Apply a warm moist pack to the ankle
Assess the ankle's passive range of motion (ROM)
The Correct Answer is B
Choice A reason: Asking the patient to try bearing weight on the injured ankle is not appropriate at this stage. Bearing weight can cause further injury or exacerbate the swelling and pain. The initial treatment should focus on reducing swelling and providing support.
Choice B reason: Elevating the ankle above heart level is appropriate because it helps to reduce swelling by promoting venous return and decreasing fluid accumulation in the affected area. Elevation is a standard first aid measure for managing acute injuries and swelling.
Choice C reason: Applying a warm moist pack to the ankle is not advisable immediately after an injury. In the acute phase, cold therapy (ice) is recommended to reduce swelling and pain. Warm therapy is more appropriate during the recovery phase, once swelling has subsided.
Choice D reason: Assessing the ankle's passive range of motion (ROM) may be necessary later, but not immediately upon arrival. The priority is to manage pain and swelling first. ROM assessments can be painful and might worsen the injury if conducted too soon.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hypotension, chills, and thirst are not characteristic signs and symptoms of a thyroid storm. Hypotension generally indicates low blood pressure, while chills and thirst are less specific symptoms that do not particularly point to thyroid storm.
Choice B reason: Lethargy, confusion, and bradycardia are not typical indicators of a thyroid storm. These symptoms might be present in other conditions but are not generally associated with the severe hypermetabolic state seen in thyroid storms.
Choice C reason: Bradycardia, hypotension, and low urine output are also not typical signs of a thyroid storm. Bradycardia (slow heart rate) and hypotension (low blood pressure) are more likely associated with severe hypothyroidism or other conditions, not the hyperactive state of a thyroid storm.
Choice D reason: Fever, tachycardia, and tremors are classic signs of a thyroid storm. A thyroid storm is a life-threatening condition characterized by an excessive amount of thyroid hormones, leading to hypermetabolic activity. This results in symptoms like a high fever, rapid heart rate (tachycardia), and tremors.
Correct Answer is D
Explanation
Choice A reason: A nursing assistant is not typically qualified to verify and administer blood products. Their role primarily involves providing basic patient care under the supervision of licensed nurses.
Choice B reason: A physician's assistant (PA) is a licensed medical professional who can perform many tasks, but verifying and administering blood products is generally within the nursing scope of practice. The PA may assist but is not the primary person for this task.
Choice C reason: The unit secretary handles administrative tasks and coordination but is not involved in clinical tasks such as verifying and administering blood products.
Choice D reason: Another registered nurse (RN) is the appropriate team member to assist in checking a unit of packed red blood cells before administration. RNs are trained and qualified to perform this task, ensuring that the right blood type and unit are administered to the patient safely.
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