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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Endocardial infection is not commonly associated with Alzheimer's disease. While it can occur, it is not a frequent infection related to chronic dementia.
Choice B reason: Brain infections, such as encephalitis, can occur but are not among the most common infections seen in patients with Alzheimer's disease.
Choice C reason: Urinary tract infections (UTIs) are common in patients with Alzheimer's disease due to factors such as immobility, incontinence, and the use of catheters. UTIs can exacerbate confusion and other dementia-related symptoms.
Choice D reason: Pneumonia is a common and serious infection in patients with Alzheimer's disease. Due to cognitive impairment, these patients may have difficulty swallowing, leading to aspiration pneumonia. Additionally, their weakened immune systems make them more susceptible to respiratory infections.
Choice E reason: Gastrointestinal infections are not typically associated with Alzheimer's disease as a common complication. While they can occur, they are not as prevalent as UTIs and pneumonia in this patient population.
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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