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
Dry mucous membranes and a dry mouth are common side effects of anticholinergic drugs like dicyclomine. These medications block the action of acetylcholine, a neurotransmitter responsible for stimulating secretions in the body. As a result, the client may experience dryness in various parts of the body, including the mouth.
Providing oral care, such as offering the client sips of water or providing a moistening agent for the mouth, can help alleviate the discomfort caused by dryness and promote oral hygiene. It is an appropriate and immediate intervention for the client's current symptoms.
Incorrect:
A. Checking vital signs may not directly address the client's dry mouth, but it is a good practice to assess the client's overall condition.
B. Monitoring hemoglobin would not be necessary in this situation, as it does not directly relate to the client's dry mucous membranes.
C. Notifying the charge nurse may be appropriate if the client's symptoms worsen or if there are other concerning factors, but the priority action in this case is to provide oral care to address the client's discomfort.
Correct Answer is A
Explanation
The practical nurse (PN) should observe minimal time, maximum distance, and protective shielding when administering direct care to a client who has four gold seed implants on a chest wall tumor.
Minimal time refers to limiting the duration of direct exposure to the client with the gold seed implants. This helps minimize the nurse's exposure to radiation.
Maximum distance refers to maintaining a safe distance from the client with the gold seed implants. The nurse should try to stay as far away as possible while still being able to provide necessary care.
Protective shielding involves using lead aprons, gloves, and other appropriate shielding materials to protect oneself from radiation exposure. These protective measures help reduce the nurse's exposure to radiation during care activities.
B. Rotating assignments with other staff during the shift may not be necessary in this situation unless there are specific staffing requirements or guidelines in place. The primary focus should be on minimizing the nurse's exposure to radiation through time, distance, and shielding.
C. Virtual observation and wearing a film badge for exposure are not applicable in this context. These measures are more relevant for monitoring radiation exposure over time and do not directly address the precautions needed during direct care.
D. Standard precautions with negative pressure isolation are not specifically indicated for a client with gold seed implants. Negative pressure isolation is typically used for clients with infectious diseases that require airborne precautions, and it is not directly related to radiation precautions.
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