your patient has been diagnosed with a left ankle sprain on the discharge instructions the physician has prescribed the rice protocol this acronym sta your patient has been diagnosed with a left ankle sprain on the discharge instructions the physician has prescribed the rice protocol this acronym sta
Logo

Nursing Elites

NCLEX NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. Your patient has been diagnosed with a left ankle sprain. On the discharge instructions, the physician has prescribed the RICE protocol. This acronym stands for:

Correct answer: Rest, Ice, Compression, Elevation

Rationale: The correct answer is Rest, Ice, Compression, Elevation. This acronym, RICE, is commonly used for the treatment of injuries like an ankle sprain. Rest allows the injured area to heal, Ice helps reduce swelling and pain (20 minutes on each hour while awake), Compression is usually achieved with an elastic bandage to minimize swelling, and Elevation of the foot above the level of the heart assists in reducing swelling and promoting healing. Choices B, C, and D are incorrect because they include irrelevant terms like Radiology and Cast, which are not part of the standard treatment protocol for an ankle sprain.

2. A client is post-op day #1 after a hemilaminectomy. The nurse removes the dressing as ordered and notes that the incision appears slightly red, with a small amount of serous drainage coming from the site. The edges of the incision are approximated. What is the next action of the nurse?

Correct answer: Assist the client to shower as ordered and monitor the site for further changes

Rationale: An incision that appears slightly red with a small amount of serous drainage on the first day following surgery is going through a normal healing process. It is important to keep the incision clean. In this case, the nurse should assist the client to shower as ordered to maintain hygiene and monitor for changes in the incision site. Instructing the client to lie prone may not be necessary and could cause discomfort. Applying antibiotic ointment without a specific order is not recommended as it can interfere with the healing process. Notifying the physician for an antibiotic order is premature at this stage since the incision is showing normal signs of healing.

3. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

Correct answer: Retract the foreskin gently to cleanse the penis

Rationale: When bathing an uncircumcised boy older than 3 years, it is essential to gently retract the foreskin to cleanse the penis. This helps in preventing the buildup of bacteria and maintaining good hygiene. Reminding the child to clean his genital area (Option A) may not be effective due to the child's cognitive development level. Perineal care should not be deferred (Option B) as it is necessary for maintaining hygiene at any age. Asking the parents why the child is not circumcised (Option D) is not relevant to the immediate care required during bathing.

4. A man has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea. The nurse is concerned about which side effect of lisinopril?

Correct answer: Hypotension

Rationale: The correct answer is 'Hypotension.' Lisinopril, an ACE inhibitor commonly used for CHF, can cause hypotension as a side effect. Persistent diarrhea can lead to dehydration, increasing the risk of hypotension in this patient. Vertigo (choice A) is not a typical side effect of lisinopril. Palpitations (choice C) are not directly associated with lisinopril use. A nagging, dry cough (choice D) is a common side effect of ACE inhibitors like lisinopril, but in this case, the patient's presentation with persistent diarrhea would make hypotension a more immediate concern.

5. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?

Correct answer: Mode of transmission

Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry. Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.

Similar Questions

The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?
Which of the following statements best describes footdrop?
The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis?
Which of the following is a true statement about palliative care?
The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99