Evolve HESI Practice Exam

What is the first action the nurse should take when observing a client's skin under an ice pack?

1. Assess the patient's pain level

2. Remove the ice pack immediately

3. Ask the client how long the ice has been applied

4. Observe the appearance of the skin

The correct answer is: Observe the appearance of the skin

The first action the nurse should take when observing a client's skin under an ice pack is to observe the appearance of the skin. This is essential because the primary concern with using an ice pack is assessing for any adverse effects on the skin, such as frostbite, redness, or other skin reactions that may indicate poor circulation or an allergy to cold therapy. By closely observing the skin, the nurse can determine if there is any immediate risk to the patient's integrity or health that may require intervention, such as removing the ice pack or modifying the treatment. Once the skin condition is assessed, other actions, like evaluating pain levels or inquiring about the duration of ice application, can follow. However, the initial focus should always be on ensuring that the skin remains healthy and intact while doing so. Keep in mind that conditions affecting the skin can change rapidly with cold applications, which makes direct observation crucial in this scenario.