Physiological Adaptation Elevate Practice Test

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What should the nurse initially do for frostbitten toes upon arrival?

Remove any wet or constricting clothing.

In frostbite care, stopping further heat loss is the first priority. Wet clothing and constricting items actively worsen cooling and restrict blood flow, so the initial action is to remove any wet footwear and clothing and take off tight rings or bands. This simple step prevents ongoing exposure to cold and prepares the tissue for gradual warming. Once wet clothing and constriction are eliminated, the nurse can proceed with rewarming and other supportive measures (like warming the area in comfortable warm water, avoiding rubbing, and protecting the toes), but those steps rely on first removing the source of continued heat loss and compression. Wrapping the toes or having the client walk would not address the immediate risk and could cause further injury.

Initiate a controlled and rapid rewarming with warm water.

Wrap each toe individually with sterile gauze.

Encourage the client to walk.

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