ch 18 and 27
A nurse assesses a patient's skin after an ice bag has been applied. Which of the following findings would indicate that the ice bag is too cold? 1) Pink, cool skin 2) Warm, red skin 3) Cool, scaly skin 4) Pale, mottled skin
4
A nurse will verify that a 33-year-old patient's heat application is set at ____ to prevent the threat of tissue injury. 1) 85°F 2) 90°F 3) 100°F 4) 105°F
4
A physician has ordered an aquathermia pad to treat a patient's deep vein thrombosis (DVT) in the lower legs. Before applying heat therapy, a nurse should assess the patient for 1) Apical pulse. 2) Respiration. 3) Anorexia. 4) Cognitive level of function and orientation.
4
An elderly patient with hip pain tells a nurse that continuous heat has been the most effective means of relieving pain. After confirming that the patient has an order for heat therapy, the nurse correctly selects which method for the patient? 1) Hot-water bottle 2) Warming blanket 3) Heating pad 4) Aquathermia K-pad
4
During report, a nurse learns that a new patient received lavage during the previous shift. The nurse correctly understands this to mean 1) Washing of the entire body with tepid water to reduce a dangerously high fever. 2) Encouraging the patient to sip ice water every minute or two to feel more comfortable during a fever. 3) Immersion in a whirlpool bath to débride the skin around a wound. 4) Irrigation of the stomach or colon with cold water to reduce a very high fever that did not respond to other treatment. Multiple Response Identify one or more choices that best complete the statement or answer the question.
4
A nurse is educating a patient about how to make a simple cold pack at home. Place the following steps of the process in order (1-4). (Enter the number of each step in the proper sequence, do not use commas). 1. Place the bag in the freezer for about 10 minutes. 2. Place the washcloth in a zip-type bag. 3. Apply the pack to the affected area. 4. Wet and fold a washcloth.
4,2,1,3
A nurse correctly identifies that which of the following patients need to be monitored more closely when using hot or cold therapy? 1) A 58-year-old with diabetes 2) A 79-year-old with prostate cancer 3) A 45-year-old with rheumatoid arthritis 4) A 1-year-old with an ear infection 5) A 62-year-old with peripheral vascular disease
5
A nurse is aware that a patient is at increased risk for falling due to orthostatic hypotension. This risk contravenes the use of which method of heat therapy? 1) Warming blanket 2) Aquathermia pad 3) A sitz bath 4) Warm soaks
3
A patient has orders for a heating pad to be placed on the lower back. A nurse teaches the patient that to prevent rebound phenomenon, the heating pad is to be removed after 1) The swelling has decreased. 2) 25 to 30 minutes. 3) The discomfort has resolved. 4) 2 to 3 hours.
2
A nurse correctly explains to a patient with a sprained wrist that cold therapy will relieve pain better than would heat by stating: 1) "Cold therapy decreases swelling and pressure on nearby nerves, which helps decrease pain." 2) "Heat therapy decreases swelling by constricting vessels and nerves, which can increase discomfort." 3) "Heat therapy decreases pain by increasing oxygen and nutrients to the injured area." 4) "Cold therapy increases the inflammatory process, which speeds healing and decreases discomfort."
1
A nurse expects that a patient diagnosed with a deep vein thrombosis (DVT) in her right lower leg will most likely have an order for which method of heat application? 1) Aquathermia pad 2) Sitz bath 3) Hot-water bottle 4) Warming blanket
1
A patient suffering from back spasms has an order for continued heat therapy at home and indicates to a nurse that he will use his heating pad. The nurse correctly advises the patient to 1) Never use any setting above medium. 2) Use the highest setting for maximum comfort. 3) Apply heat for 1 hour every 3 hours. 4) Not use heat because cold therapy is more effective at stopping spasms.
1
A patient with congestive heart failure (CHF) presents to the emergency department with muscle spasms in the lower back. Which of the following would not be an appropriate application of heat? 1) Forced-air warming blanket 2) Commercial heat pack 3) Hot compress 4) Heat therapy can never be used safely in a patient with CHF.
1
When using a refillable ice bag, a nurse correctly 1) Fills the bag one-half to two-thirds with ice and some water. 2) Fills the bag completely with water and then freezes it. 3) Fills the bag completely with ice. 4) Fills the bag one-quarter to one-third with ice and then partially melts the ice in the microwave.
1
A nurse understands that special precautions must be taken when a whirlpool bath is administered to which of the following patients? 1) A patient who has been sedated to undergo a procedure 2) A 70-year-old patient 3) A patient with a wound that requires débridement 4) A patient with physical therapy scheduled 5) An 8-year-old patient
1 and 5
A nurse is satisfied that the mother of a 2-year-old with a history of febrile seizures understands how to effectively decrease body temperature when the mother states: 1) "I will put my child in a lukewarm bath, making sure the temperature of the water is somewhere between 105°F and 110°F." 2) "When his temperature reaches 10B.5°F, I will carefully place ice bags in the armpits and groin." 3) "If his fever spikes, I will bring him to the emergency department because he will most likely need to be lavaged with cold water." 4) "If I put ice bags around his body, his temperature will not get high enough to cause seizures."
2
A physician has ordered a sitz bath for a patient. The nurse understands that it is important to check the patient's chart 1) To see whether the patient has had a tub or whirlpool bath before and prefers that treatment. 2) To see whether the patient has had a sitz bath before and what the response was. 3) To see whether the patient has an active infection that would contraindicate the sitz bath. 4) To see whether the patient is mobile, in which case a tub or whirlpool bath is preferable to a sitz bath.
2
While bathing a patient, a nurse finds that the patient's previous IV site is tender and the vein feels hard upon palpation, indicating inflammation. The nurse should apply 1) A cold pack using a glove filled with ice. 2) A warm compress using a washcloth dipped in hot water. 3) Heat by submerging the arm in a basin of very warm water. 4) A refreezable chemical cold pack.
2
A nurse applies a cooling blanket to a patient with a temperature of 10E.4°F. The nurse would recognize which of the following as an indication of therapeutic effectiveness? 1) The patient begins to shiver. 2) The blood pressure and pulse increase. 3) The temperature slowly falls to 100°F. 4) The level of consciousness decreases.
3
A nurse is preparing to administer a sponge bath to reduce fever in a patient. Which of the following is the most appropriate action to take? 1) Lower the temperature of the room to aid in reducing the patient's body temperature. 2) Place ice in a bowl of water so that it is cold enough to have the desired effect. 3) Assess the patient's temperature to have a baseline. 4) Plan to provide care to other patients after applying moist cloths to this patient's axilla and groin.
3
A nurse suspects that the ice bag on a patient's left foot is too cold because the patient is complaining of 1) Feeling chilled. 2) Increased swelling. 3) A burning sensation. 4) Feeling confused.
3
A patient comes to urgent care with a swollen, painful ankle. While the patient is waiting to be seen by the physician, a nurse could appropriately 1) Apply a cold pack to the ankle to reduce pain and edema. 2) Apply a hot pack to the ankle to improve mobility and promote healing. 3) Confirm that there are standing orders to apply ice to recent, localized joint injuries. 4) Confirm that there are standing orders to apply heat to recent, localized injuries involving edema.
3
Before applying a warm pack to reduce a patient's discomfort from back spasms, a nurse will 1) Warm the towel in the microwave. 2) Check peripheral pulses for a baseline. 3) Assess the skin for edema and color. 4) Prepare the warm pack using sterile technique.
3
When applying cold therapy, a nurse correctly understands that 1) Ice or another source of cold should be placed directly on the patient's skin. 2) Cold therapy works best when alternated with heat therapy. 3) A thin cloth barrier should be placed between the source of cold and the patient's skin. 4) The treatment should be applied for about 45 minutes.
3
Following a nurse's explanation of why a warm pack should be applied to an infected hang nail, a patient demonstrates understanding by stating: 1) "Heat to the area causes the blood vessels to constrict, concentrating the white blood cells needed to fight infection." 2) "If I apply moist heat to the area, it will decrease the metabolism of the germs that are trying to multiply." 3) "Applying heat will decrease the blood flow and as a result will increase my body's ability to fight infection." 4) "My body's ability to fight off infection will be enhanced by allowing more white blood cells to get to the wound."
4