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 A
Explanation
The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates blowing forcefully into the mouthpiece. The proper way to use an incentive spirometer is to sit upright, hold the spirometer upright, place your mouth around the mouthpiece, breathe out slowly, and then inhale slowly only through your mouth as deeply as you can. Blowing forcefully into the mouthpiece is not the correct way to use an incentive spirometer.
B. Exhaling slowly after two seconds: This is actually a correct action when using an incentive spirometer. The proper way to use an incentive spirometer is to exhale slowly before inhaling deeply.
C. Using a tight seal around the mouthpiece: This is also a correct action when using an incentive spirometer. It’s important to create a tight seal around the mouthpiece with your lips to ensure that you’re inhaling and exhaling only through your mouth.
D. Sitting upright during the treatment: This is another correct action when using an incentive spirometer. Sitting upright helps you to breathe more deeply and fully, which is the goal of using an incentive spirometer.
Correct Answer is C
Explanation
The correct answer is C.
Choice A reason:
Repeating the heel stick for glucose in one hour is not the best first action because it delays necessary treatment and the infant's glucose could drop further, potentially causing harm.
Choice B reason:
Offering nipple feedings of 10% dextrose is not the initial treatment of choice for neonatal hypoglycemia. Oral dextrose gel may be used, but the priority is to provide a source of nutrition, such as breast milk or formula, which offers more sustained glucose levels.
Choice C reason:
Begin frequent feedings of breast milk or formula. This is the first intervention to implement because the infant's current glucose level is below the normal neonatal range of [30 to 60 mg/dL or 1.7 to 3.3 mmol/L], indicating hypoglycemia, which is common in infants of mothers with gestational diabetes. Immediate feeding can help raise the blood glucose level safely.
Choice D reason:
Assessing for signs of hypocalcemia is not the immediate priority. While hypocalcemia can occur in newborns, particularly those with maternal diabetes, the current symptoms and glucose level suggest hypoglycemia is the primary concern. Signs of hypocalcemia include irritability, muscle twitches, jitteriness, tremors, and poor feeding, which can overlap with hypoglycemia symptoms. However, the heel stick glucose level clearly indicates hypoglycemia, which should be addressed first.
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