Which intervention is the most important for the practical nurse (PN) to implement when applying an ice pack to a client?
Wrap the bag in place for comfort.
Secure a protective cover over the bag.
Give directions to leave the pack in place.
Fill the ice pack with crushed ice
The Correct Answer is B
The most important intervention for the practical nurse (PN) to implement when applying an ice pack to a client is to secure a protective cover over the bag. This is essential to protect the client's skin from direct contact with the ice pack, which can cause tissue damage, frostbite, or discomfort.
Securing a protective cover, such as a thin cloth or towel, between the ice pack and the client's skin helps to create a barrier and prevent excessive cold exposure. It allows for the therapeutic benefits of the ice pack, such as reducing swelling and pain, while minimizing the risk of skin damage.
Incorrect:
A. While wrapping the bag in place for comfort is important, it is not the most critical intervention compared to ensuring the protection of the client's skin.
C. Giving directions to leave the pack in place is a general instruction for the client to follow the prescribed treatment, but it does not specifically address the importance of using a protective cover.
D. The type of ice used, whether crushed or cubed, may vary based on availability and preference, but it does not take precedence over the need to protect the client's skin with a cover.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
The PN should instruct the UAP to observe and report any ear drainage after removing the device, as this may indicate an infection or irritation of the ear canal. The PN should also instruct the UAP to verify that the device is labeled with client's identification, as this can prevent mix-ups or misplacement of the device. The PN should also instruct the UAP to remove ear wax from the device's surface, as this can improve the sound quality and prevent damage to the device.
The other options are not correct because:
a. Keeping the battery door closed during storage is not a correct instruction, as it can drain the battery and shorten its life span. The PN should instruct the UAP to keep the battery door open during storage, as this can conserve the battery power and prevent corrosion.
c. Storing the device on the window sill to prevent loss is not a correct instruction, as it can expose the device to heat, moisture, or sunlight, which can damage its components or affect its function. The PN should instruct the UAP to store the device in a dry, cool, and safe place, such as a case or a drawer.
Correct Answer is C
Explanation
Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry: This finding indicates an abnormality in the heart's electrical conduction system. PVCs are extra, abnormal heartbeats that originate in the ventricles. They can sometimes be benign, but they can also be associated with underlying heart conditions or electrolyte imbalances. Since the client is experiencing dizziness and tingling, which could be related to cardiac function, it is important to report this finding to the healthcare provider for further evaluation and appropriate management.
Incorrect:
A. Regular heart rate of 100 beats per minute on telemetry: This finding describes a heart rate within the normal range (60-100 beats per minute for adults). It does not indicate any immediate concerns or abnormalities that would require reporting to the healthcare provider in this context.
B. Hypoactive bowel sounds on assessment: Following a small bowel resection, it is common for bowel sounds to be temporarily reduced or absent due to the surgical manipulation and the bowel's response to anesthesia. Hypoactive bowel sounds alone do not directly relate to the client's reported symptoms of dizziness and tingling in digits, nor do they suggest an immediate need for reporting to the healthcare provider.
D. Hyperactive bowel sounds on assessment: Hyperactive bowel sounds, characterized by increased loudness and frequency, can occur due to conditions such as gastroenteritis or bowel obstruction. However, in the context of a client who has undergone a small bowel resection and is on NPO status, hyperactive bowel sounds would not be expected and may indicate a potential complication. While it is important to monitor and document this finding, it is not directly related to the client's reported symptoms and does not require immediate reporting to the healthcare provider in this scenario.
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