A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following client statements indicates a need for further instruction?

"I will get up and walk with the physical therapy aide."

"I will do leg exercises every hour while I am awake."

"I will take off my antiembolic stockings before I go to bed."

"I will use a footstool while I sit in a chair."

Answer and Explanation

The Correct Answer is C

A.   Getting up and walking with the physical therapy aide promotes early mobility and is a positive statement.
B.   Doing leg exercises every hour while awake helps prevent complications such as deep vein thrombosis (DVT).
C.   Leaving antiembolic stockings on during sleep helps prevent DVT, so the client's statement is incorrect.
D.   Using a footstool while sitting in a chair promotes proper positioning and comfort.

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Correct Answer is C

Explanation

A. Choosing a vein that is soft on palpation may indicate it's not suitable for IV insertion. A vein with a slight bounce or resilience is preferable.
B. Selecting a vein in the client's dominant arm is not a primary consideration. Both arms are

usually suitable, and the choice depends on factors such as accessibility and patient preference.

C. Selecting a site distal to previous venipuncture attempts reduces the risk of complications such as infiltration or infection and allows for optimal vein preservation.
D. Choosing the most proximal vein in the extremity is not typically recommended for peripheral IV insertion. Veins more distal to the body are often preferred for initial attempts, with
consideration for vein integrity and accessibility.

A. Wrapping the finger in a warm cloth B. Rubbing the fingertip with an alcohol pad C. Puncturing the side of the fingertip D. Elevating the finger above heart level

Correct Answer is D

Explanation

A. Wrapping the finger in a warm cloth helps improve blood flow and can facilitate the blood sample collection.
B. Rubbing the fingertip with an alcohol pad cleans the site before the puncture.

C. Puncturing the side of the fingertip is less painful and avoids the pain receptors.

D. The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.

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A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following client statements indicates a need for further instruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Correct Answer is D

Explanation

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