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 D
Explanation
Verifying the completion of all new prescriptions is crucial because it ensures that necessary medications or treatments are not delayed or missed for the clients. By reviewing the new prescriptions, the PN can ensure that any necessary medications or treatments are ordered and completed as required. This task takes priority because it directly impacts the immediate care and well-being of the clients.
While the other tasks mentioned are also important, they are not as time-sensitive or critical as verifying the completion of new prescriptions:
A. "Clean up and organize the nurses' work-station": While maintaining a clean and organized work-station is important for efficiency and safety, it can be done after the more critical tasks have been completed.
B. "Write a narrative shift summary for each client": Providing shift summaries is important for effective communication and continuity of care, but it can be done after ensuring the completion of new prescriptions, as it involves documenting and reviewing the events and assessments that occurred during the shift.
C. "Calculate and record intake and output totals": Tracking intake and output is important for assessing fluid balance, but it can also be done after verifying the completion of new prescriptions, as it involves documenting and calculating fluid volumes.
Correct Answer is D
Explanation
Regular insulin is the medication of choice for treating DKA. Its main action is to lower blood glucose levels by promoting the uptake of glucose into cells and inhibiting the production of glucose by the liver. Therefore, checking the fingerstick blood glucose level is an important indicator of the effectiveness of the insulin treatment.
A decrease in the blood glucose level indicates that the insulin is working to lower the high blood sugar associated with DKA. This measurement helps the PN assess the response to treatment and adjust the insulin dosage if necessary.
The other actions mentioned are also important assessments in the care of a client with DKA, but they do not specifically evaluate the effectiveness of the insulin dosage:
A. Smelling the client's breath for resolution of a fruity odor is important as it indicates a decrease in ketone production, which is a marker of improving DKA. However, it does not directly evaluate the effectiveness of the insulin dosage.
B. Determining the client's orientation to time and space is part of assessing their neurological status, which is crucial in managing DKA. However, it does not specifically assess the effectiveness of the insulin dosage.
C. Measuring the client's urinary output for an increased volume is important to monitor hydration status and renal function, but it does not directly evaluate the effectiveness of the insulin dosage.
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