Practice Question
The nurse observes that a client has removed the covering from an ice pack applied to the knee: Which action should the nurse take first?
Answer Choices:
Correct Answer:
Observe the appearance of the skin under the ice pack.
Rationale:
🔷 Immediate assessment is essential because direct ice-to-skin contact can cause frostbite, tissue ischemia, or skin breakdown within minutes.
🔷 The nursing process always begins with assessment before intervention; checking the skin ensures the nurse acts based on accurate findings.
🔷 Visualizing the skin allows the nurse to identify early signs of erythema, blanching, or damage, which guide whether the therapy can safely continue.
🔷 Acting without assessment—such as reapplying ice or giving instructions—may overlook existing injury and worsen tissue compromise.
🔷 Once safety is confirmed, the nurse can proceed with teaching about the importance of a covering and safe cryotherapy practices.
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This question is from Hesi RN Foundations of Nursing -Preassessment 1 which contains 55 questions.
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From Exam
Hesi RN Foundations of Nursing -Preassessment 1
55 Questions
View Full Exam Start PracticingQuestion Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI Exam(s)
- Domain: Hesi Fundamentals of Nursing
- Answer Choices: 4