Nokea
A patient has an erythematous area at the site where you just discontinued an IV infusion. There is no edema, but the patient complains of the site being very tender. Which of the following would be the treatment of choice?
- A. Telling the patient the tenderness will subside without treatment
- B. Administering a sitz bath
- C. Applying an ice pack
- D. Applying a warm pack
Correct Answer: C
Rationale: Ice reduces inflammation and tenderness at the IV site by causing vasoconstriction.
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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.
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.
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.
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.
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.