A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
"I'll keep a heating pad on the calf of my right leg when I am lying down."
"I'll wrap a warm, wet towel around my right calf every 4 hours."
"I'll place my leg under a heat lamp every 3 hours."
"I will sit on the side of the tub and soak my right leg two times every day."
The Correct Answer is B
Rationale:
A. Keeping a heating pad on the leg for extended periods can lead to burns or skin damage. Heat therapy should be applied intermittently with breaks to prevent overheating.
B. Wrapping a warm, wet towel and applying it intermittently is appropriate for localized heat therapy and can help reduce inflammation and promote healing.
C. Using a heat lamp may not provide consistent or controlled heat application and is not the standard approach for treating cellulitis.
D. Soaking the leg in a tub is not recommended as it may introduce bacteria and potentially worsen the infection.
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Correct Answer is C
Explanation
Rationale:
A. Observing the final 2 minutes is not sufficient for detecting acute transfusion reactions, which can occur at any time during the transfusion.
B. Observing the final 15 minutes is also not adequate; reactions can occur earlier.
C. The first 15 minutes is the most critical time for observing for transfusion reactions, as most reactions occur during this period.
D. The first 2 minutes are too brief to detect potential transfusion reactions, which typically manifest within the first 15 minutes.
Correct Answer is A
Explanation
Rationale:
A. Sore throat and muscle aches are common symptoms of agranulocytosis, a serious side effect of clozapine, indicating a potentially dangerous drop in white blood cells.
B. Severe restlessness is not a primary indicator of agranulocytosis but could be related to other side effects or symptoms.
C. Increased anxiety and suicidal ideations are not specific symptoms of agranulocytosis but can be related to psychiatric conditions or medication effects.
D. Respiratory depression and a comatose state are not typical signs of agranulocytosis and would indicate a more severe, different medical emergency.