A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days.
Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?

“Perform regular isometric exercises.”.

“Increase your intake of protein.”.

“Dangle your legs over the side of the bed.”.

“Use your incentive spirometer.”.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. “Dangle your legs over the side of the bed.” This helps prevent orthostatic hypotension, which is a form of low blood pressure that happens when standing after sitting or lying down.

Dangling the legs over the side of the bed allows blood to flow back to the heart and increases blood pressure before standing up.

Choice A is wrong because “Perform regular isometric exercises.” Isometric exercises are muscle contractions without movement, such as squeezing a ball or clenching a fist.

These exercises do not help with orthostatic hypotension because they do not improve blood circulation or blood pressure.

Choice B is wrong because “Increase your intake of protein.” Protein intake does not affect orthostatic hypotension directly.

However, staying hydrated by drinking plenty of fluids can help prevent or manage the condition by maintaining blood volume and blood pressure.

Choice D is wrong because “Use your incentive spirometer.” An incentive spirometer is a device that helps improve lung function after surgery by encouraging deep breathing.

It does not prevent orthostatic hypotension because it does not affect blood pressure or blood flow.

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Correct Answer is C

Explanation

Correct answer: C

A. A client who has a venous stasis ulcer: This is less likely to cause a false positive result. While ulcers can bleed, the fecal occult blood test is designed to detect small amounts of blood in the stool, not necessarily blood from other sources like venous stasis ulcers.

B. A client who has peripheral hematomas: Peripheral hematomas are typically not related to the fecal occult blood test. They generally wouldn’t affect the results unless there was significant bleeding or if the hematomas were a result of an underlying bleeding disorder.

C. A client who underwent a barium swallow study: This is the most likely to cause a false positive result. Barium used in the study can sometimes appear as a false positive on the test due to its interference with the chemical reactions used to detect blood.

D. A client who takes an iron supplement: Iron supplements can actually cause a false negative result rather than a false positive because they may darken the stool and mask the presence of blood.

A. Bear weight on the unaffected leg. B. Keep the crutches at the level of the axillae. C. Stand with the crutch tips against the feet. D. Hold the arms straight when walking.

Correct Answer is A

Explanation

This gait pattern is used when one of the lower extremities is unable to fully bear weight due to fracture, amputation, joint replacement etc12 The client should advance both crutches and the affected leg as one unit, and then bring the unaffected leg forward to the crutches as the second unit

Choice B is wrong because keeping the crutches at the level of the axillae can cause nerve damage and reduce circulation.

The crutches should be positioned with 2 fingers of distance between the axilla and the axilla pad with the elbow flexed between 20-30 degrees

Choice C is wrong because standing with the crutch tips against the feet can cause instability and increase the risk of falling.

The crutch tips should be placed about 15 cm (6 inches) in front of and 15 cm to the side of each foot

Choice D is wrong because holding the arms straight when walking can cause fatigue and strain on the shoulders and wrists.

The client should keep a slight bend in the elbows when walking with crutches

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A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days.
Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?