The nurse will include which intervention for the patient newly admitted with cellulitis of the right foot?
Encourage frequent ambulation
Maintain foot in a dependent position.
Apply warm, moist heat
Wrap the foot snugly in the blanket
The Correct Answer is C
A. Ambulation may worsen the condition as it could increase swelling or spread infection.
B. This may increase swelling and should generally be avoided in cellulitis.
C. This helps to improve circulation and reduce swelling in cellulitis.
D. Wrapping the foot tightly could exacerbate swelling and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Decreasing Glasgow Coma scores indicate a worsening neurological status and reduced consciousness.
B. Swelling of the optic nerve (papilledema) is a sign of increased ICP and indicates worsening conditions.
C. A respiratory rate of 12/min may be within normal range for some individuals but can also be a sign of impending respiratory depression in cases of severe ICP. However, it is not as immediately concerning as the other options in this case.
D. Changes in pupil size and shape are classic signs of worsening ICP. Unequal or nonreactive pupils are a key indicator.
E. Blood pressure of 108/74 mm Hg is not concerning unless it represents a significant drop from the baseline; other signs of worsening ICP are more critical in this case.
Correct Answer is D
Explanation
A. A ventriculostomy involves inserting a catheter into the ventricles of the brain to monitor ICP, not a procedure for instilling drugs.
B. A ventriculostomy involves the insertion of a catheter to monitor ICP, not an internal transducer.
C. Cerebrospinal fluid (CSF) samples can be taken via ventriculostomy; the procedure does not prevent this.
D. A ventriculostomy measures the pressure within the brain’s ventricles to monitor intracranial
pressure, which is the correct understanding.
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