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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Decreased magnesium level: Primary aldosteronism typically affects sodium and potassium balance, but it is less likely to cause significant changes in magnesium levels. Therefore, a decreased magnesium level is not the expected electrolyte imbalance in this condition.
B) Decreased total calcium level: Primary aldosteronism does not primarily affect calcium metabolism. While calcium levels could be influenced indirectly, they are not a primary concern in this disorder. Hence, a decreased total calcium level is not expected.
C) Elevated phosphate level: Phosphate levels are generally not directly influenced by aldosterone. Elevated phosphate levels might be seen in other conditions, but they are not characteristic of primary aldosteronism.
D) Elevated sodium level: Primary aldosteronism leads to excess production of aldosterone, which promotes sodium retention by the kidneys. This retention causes elevated sodium levels, resulting in hypernatremia, and contributes to symptoms like frequent urination due to the body's attempt to excrete excess sodium through increased urine production.
Correct Answer is D
Explanation
A) Protective environment
This type of isolation is used for clients with weakened immune systems to protect them from infections. It is not necessary for pertussis, which requires droplet precautions to prevent spread.
B) Airborne precautions
These are used for diseases that are spread through tiny droplets that remain in the air, such as tuberculosis. Pertussis spreads through larger respiratory droplets, not lingering in the air, so airborne precautions are not needed.
C) Contact precautions
These are used for infections spread by direct touch or contact with surfaces. Pertussis primarily spreads through respiratory droplets rather than direct contact, making contact precautions unnecessary.
D) Droplet precautions
Droplet precautions are appropriate for pertussis, as it spreads via respiratory droplets when an infected person coughs or sneezes. This involves wearing masks and maintaining distance to prevent transmission.
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