A client presents the emergency department with a Grade II ankle sprain. Which of the following interventions should the nurse implement?
Encourage the client to walk on the injured ankle to promote circulation.
Immerse the ankle in want water immediately after the in
Apply ice to the affected ankle for the first 24-72 hours.
Perform deep tissue massage on the injured area to reduce pain.
The Correct Answer is C
A. Encourage the client to walk on the injured ankle to promote circulation. Weight-bearing activities should be avoided initially after a Grade II sprain to prevent further injury.
B. Immerse the ankle in warm water immediately after the injury. Ice, rather than warmth, is recommended immediately following an injury to reduce swelling and inflammation.
C. Apply ice to the affected ankle for the first 24-72 hours. Applying ice for 24-72 hours helps reduce swelling and pain by causing vasoconstriction and controlling inflammation in the acute phase.
D. Perform deep tissue massage on the injured area to reduce pain. Massaging a newly sprained ankle can aggravate inflammation and cause additional tissue damage.
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Correct Answer is B
Explanation
A. The gallbladder became infected by a virus and needs to be removed. Gallstones are not caused by viral infections; they typically develop from an imbalance in the substances that make up bile, such as cholesterol and bilirubin.
B. The gallbladder has become inflamed due to the cholesterol in the gallstones. Cholesterol is a common component of gallstones, and these stones can cause inflammation of the gallbladder (cholecystitis), leading to the need for removal.
C. The gallbladder has become blocked by a tumor and is no longer working. Tumors can obstruct the gallbladder, but this is not the cause of gallstones or the primary reason for a cholecystectomy.
D. The gallbladder has become inflamed due to a build-up of gallstones that are blocking the common bile duct. This describes choledocholithiasis, a condition where gallstones block the common bile duct, but it is not the primary cause of gallbladder inflammation requiring a cholecystectomy.
Correct Answer is ["A","C","D","E"]
Explanation
A. Ensure that the client's urine output is at least 1 ml/kg/hr. Adequate urine output is essential before administering IV potassium to ensure the kidneys are functioning properly and can handle the increased potassium load, preventing hyperkalemia.
B. Ensure potassium infusion is prepared with 5% dextrose solution. While IV potassium can be mixed with normal saline or dextrose solutions, the specific diluent will depend on the clinical scenario. This isn't necessarily a standard requirement, so it may not be appropriate for all situations.
C. Educate the client regarding high-potassium foods. Education on high-potassium foods helps the client maintain potassium levels after treatment, reducing the need for future supplementation.
D. Repeat blood serum potassium levels. Rechecking potassium levels ensures the patient reaches a safe and therapeutic range and helps monitor for signs of overcorrection or continued hypokalemia.
E. Cardiac monitoring during infusion. Cardiac monitoring is critical, as hypokalemia and potassium replacement can affect heart rhythm and lead to arrhythmias.