Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?
A. 2+ pitting edema
2+ pitting edema is not a contraindication to cold application; in fact, cold application can help reduce edema.
B. 7.5 cm (3 in) diameter bruise on the ankle
A 7.5 cm (3 in) diameter bruise on the ankle is not a contraindication to cold application; cold can help reduce swelling and alleviate pain.
C. Capillary refill 4 seconds
Capillary refill of 4 seconds suggests compromised blood flow, and cold application may further impair circulation. It is a contraindication.
D. Warts on the affected ankle
Warts on the affected ankle are not a contraindication to cold application.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Fundamentals Proctored Exam 6. Take the full exam now
Full Explanation
A. 2+ pitting edema is not a contraindication to cold application; in fact, cold application can help reduce edema.
B. A 7.5 cm (3 in) diameter bruise on the ankle is not a contraindication to cold application; cold can help reduce swelling and alleviate pain.
C. Capillary refill of 4 seconds suggests compromised blood flow, and cold application may further impair circulation. It is a contraindication.
D. Warts on the affected ankle are not a contraindication to cold application.
Similar Questions
A parish nurse is developing a program of educational sessions to meet the needs of the older adults in the congregation. Which of the following is the best approach to enhance the development of suitable programs?
A. Survey the target population to determine topics of interest related to health issues.
Surveying the target population is the best approach to identify the specific interests andhealth concerns of the older adults, ensuring that the programs are relevant and tailored to their needs.
B. Determine availability of health care providers from the community to provide the presentations.
Determining the availability of health care providers is a logistical consideration but may not necessarily address the specific interests or needs of the older adults.
C. Base the programs on their developmental stage emphasizing changes in function and physical capabilities.
Basing the programs on their developmental stage is important, but surveying the population allows for a more comprehensive understanding of their diverse needs and preferences.
D. Review the Healthy People 2020 Objectives to identify health issues affecting older adults.
Reviewing Healthy People 2020 Objectives is a valuable resource, but it may not capture the specific interests or concerns of the local population.
Full Explanation
A. Surveying the target population is the best approach to identify the specific interests and
health concerns of the older adults, ensuring that the programs are relevant and tailored to their needs.
B. Determining the availability of health care providers is a logistical consideration but may not necessarily address the specific interests or needs of the older adults.
C. Basing the programs on their developmental stage is important, but surveying the population allows for a more comprehensive understanding of their diverse needs and preferences.
D. Reviewing Healthy People 2020 Objectives is a valuable resource, but it may not capture the specific interests or concerns of the local population.
A nurse in an acute care facility is preparing to transfer a client to a long-term care facility.
Which of the following information should the nurse include in the hand-off report?
A. Frequency of previous vital sign measurement
The frequency of previous vital sign measurements may be important but is not the most critical information to communicate during a transfer.
B. Effectiveness of the last dose of pain medication
The effectiveness of the last dose of pain medication is crucial information for the receiving facility to manage the client's pain appropriately.
C. Number of family members who have visited
The number of family members who have visited is important for emotional support but may not be the priority for the receiving facility.
D. Time of the client's last bath
The time of the client's last bath is relevant but may not be as critical as information related to pain management during the hand-off report.
Full Explanation
A. The frequency of previous vital sign measurements may be important but is not the most critical information to communicate during a transfer.
B. The effectiveness of the last dose of pain medication is crucial information for the receiving facility to manage the client's pain appropriately.
C. The number of family members who have visited is important for emotional support but may not be the priority for the receiving facility.
D. The time of the client's last bath is relevant but may not be as critical as information related to pain management during the hand-off report.
A nurse observes an assistive personnel (AP) empty an indwelling urinary catheter drainage bag while not wearing gloves. Which of the following interventions should the nurse take first?
A. Provide the AP with a copy of the unit's policy.
Providing the AP with a copy of the unit's policy may be done but is not the first step. Direct communication is important for immediate feedback.
B. Notify the charge nurse about the incident.
Notifying the charge nurse is appropriate but may not be the first action when direct communication with the AP can address the issue.
C. Talk with the AP about the technique used.
Talking with the AP about the technique used is the first and immediate action to address the observed lapse in infection control practices.
D. Conduct an in-service on standard precautions.
Conducting an in-service on standard precautions is a broader intervention and may be considered after addressing the immediate concern with the AP.
Full Explanation
A. Providing the AP with a copy of the unit's policy may be done but is not the first step. Direct communication is important for immediate feedback.
B. Notifying the charge nurse is appropriate but may not be the first action when direct communication with the AP can address the issue.
C. Talking with the AP about the technique used is the first and immediate action to address the observed lapse in infection control practices.
D. Conducting an in-service on standard precautions is a broader intervention and may be considered after addressing the immediate concern with the AP.