Author Question: The nurse applies an aquathermia heat pack to the client's right leg and removes it after no more ... (Read 78 times)

Pineappleeh · **on:** Jun 25, 2018

The nurse applies an aquathermia heat pack to the client's right leg and removes it after no more than 45 minutes. What is the nurse trying to avoid by completing this action?

1. Vasodilation
2. Rebound phenomenon
3. Heat tolerance
4. Systemic effects

Question 2

The nurse is documenting care for a client who required wound care requiring sterile technique. Which items will the nurse include in the documentation in the medical record for this client?

1. The use of sterile skill during the wound care

2. The number and type of sterile supplies available for the next provider

3. The location and appearance of the wound

4. The client's tolerance of the procedure

5. The role of the unlicensed assistive personnel (UAP) in maintaining sterile technique
Standard Text: Select all that apply.

rleezy04 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2

A rebound phenomenon occurs at the time the maximum therapeutic effect is achieved and the opposite effects begin, and can result in a burn. Vasodilation is the desired effect of heat. Heat tolerance begins shortly after applying the heat pack as the skin adapts to the warmth. Systemic effects will occur when heat is applied to a large localized area of the body, increasing cardiac output and pulmonary ventilation.

Answer to Question 2

Correct Answer: 1,3,4

The nurse must document the use of sterile skill when performing wound care that requires sterile technique. The nurse would also include documentation of the size and appearance of the wound and how the client tolerated the procedure. It is not necessary to include which sterile supplies are available for the next provider. The nurse cannot delegate the maintenance of the sterile field and sterile technique to the UAP.