Nokea
A child has a minor cut on her scalp that continues to ooze blood after the wound is cleansed. Which type of heat or cold application would be appropriate in this situation?
- A. Examination glove filled with ice
- B. Sterile warm compress
- C. Tepid sponge bath
- D. Warm K-pad
- E. Cooling blanket
Correct Answer: A
Rationale: Cold (ice) promotes vasoconstriction, reducing bleeding in a minor cut.
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During a heat application, which of the following assessment findings would indicate the heat pack should be removed immediately?
- A. Skin is pale pink.
- B. Skin is dark red.
- C. Temperature of the site is slightly warmer than surrounding skin.
- D. Patient denies discomfort.
- E. Skin is starting to look 'bubbly.'
- F. Skin is hot to the touch.
Correct Answer: B,E,F
Rationale: Dark red skin, bubbly appearance, and hot skin indicate potential burns, requiring immediate removal of the heat pack.
During a cold application, which of the following assessment findings would indicate the cold pack should be removed immediately?
- A. Skin is pink.
- B. Skin is white.
- C. Skin is mottled.
- D. Patient complains of a 'burning' sensation.
- E. Skin is very cool to the touch.
- F. Patient states the itching from the rash site is decreasing.
Correct Answer: B,C,D
Rationale: White, mottled skin and a burning sensation indicate tissue damage from excessive cold, necessitating immediate removal.
The nurse is preparing a sitz bath for a postpartum mother. The nurse understands the water must be hung to what level?
- A. 18 to 24 inches
- B. 15 to 20 inches
- C. 17 to 25 inches
- D. 10 to 22 inches
Correct Answer: B
Rationale: Sitz bath water is typically hung 15-20 inches above the patient to ensure proper flow and comfort.
The nurse understands that local heat application can cause which of the following?
- A. Vasodilation
- B. Increased cellular metabolism
- C. Vasoconstriction
- D. Relaxed muscles
- E. Decreased pain
- F. Decreased blood flow to the site
Correct Answer: A,B,D,E
Rationale: Heat causes vasodilation, increases metabolism, relaxes muscles, and reduces pain by improving blood flow.
The nurse understands that which of the following methods are moist heat?
- A. Hot compresses
- B. Soaks
- C. Sitz baths
- D. Whirlpool baths
Correct Answer: A,B,C,D
Rationale: Hot compresses, soaks, sitz baths, and whirlpool baths all involve moist heat, promoting tissue relaxation and healing.