A nurse in a clinic is teaching preventative measures with a female client who has a history of deep-vein thrombosis. Which of the following statements should the nurse include in the teaching?

"Sit with your legs in a dependent position when in a chair."

"Prevent dehydration by drinking at least 2.5 liters fluids each day."

"Massage your calves after sitting for 2 hours."

"Roll stretchy nylon stockings down to the upper part of your calves."

Answer and Explanation

The Correct Answer is B

A) "Sit with your legs in a dependent position when in a chair."
Sitting with legs in a dependent position can decrease blood flow and increase the risk of clot formation. It's important to elevate the legs when sitting to promote venous return and reduce the risk of deep-vein thrombosis (DVT).

B) "Prevent dehydration by drinking at least 2.5 liters fluids each day."
Staying well-hydrated helps maintain good blood circulation and prevents blood from becoming too viscous, reducing the risk of clot formation. Adequate fluid intake is crucial in preventing DVT.

C) "Massage your calves after sitting for 2 hours."
Massaging the calves is not recommended for someone with a history of DVT, as it may dislodge a clot. Instead, clients should be encouraged to move or stretch their legs regularly to improve circulation.

D) "Roll stretchy nylon stockings down to the upper part of your calves."
Proper use of compression stockings involves wearing them as prescribed, which typically means keeping them fully extended to ensure consistent pressure along the leg. Rolling them down can create a tourniquet effect and is not recommended.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A) Muscle twitching:
Muscle twitching, also known as tetany, is a common manifestation of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to symptoms such as muscle cramps, spasms, and twitching. This is a key clinical sign that helps in diagnosing hypocalcemia.
B) Bounding pulse:
A bounding pulse is not typically associated with hypocalcemia. Instead, it is more often seen in conditions such as fluid overload or hyperdynamic circulatory states, where there is increased cardiac output or vascular volume.
C) Hypertension:
Hypertension is not a common manifestation of hypocalcemia. Hypocalcemia is more likely to cause hypotension due to its effect on cardiac contractility and vascular tone, rather than causing high blood pressure.
D) Decreased bowel sounds:
Decreased bowel sounds are not commonly associated with hypocalcemia. Hypocalcemia affects neuromuscular function, but it typically causes increased gastrointestinal motility rather than decreased motility, which would lead to hyperactive bowel sounds rather than decreased ones.

A. Check skin temperature distal to the injury with the dorsum of the hand. B. Press the heel of the foot to determine capillary refill. C. Monitor sensation by palpating the pad of the great toe with a blunt needle. D. Compare the color of the skin proximal to the injury with the other extremity.

Correct Answer is A

Explanation

A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.

B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.

C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.

D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.

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A nurse in a clinic is teaching preventative measures with a female client who has a history of deep-vein thrombosis. Which of the following statements should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has hypocalcemia. Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who has musculoskeletal injuries to the left lower extremity. Which of the following assessments should the nurse perform to evaluate the neurovascular status of the client's extremity?

Correct Answer is A

Explanation

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