A nurse is collecting data from a client who is immobile and has a potential deepvein thrombosis.
Which of the following findings should the nurse report to the provider?

The correct answer is choice D. Flex hips and knees when assisting the client to a standing position.

Choice A rationale:

Raising the bed to waist level before moving the client is not recommended because it can increase the risk of falls and injuries. The bed should be at a height that allows the nurse to maintain proper body mechanics and ensure the client’s safety during the transfer.

Choice B rationale:

Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect. The nurse should pivot on the foot closest to the bed to maintain stability and control during the transfer.

Choice C rationale:

Standing on the client’s stronger side when moving the client into the chair is not the best practice. The nurse should stand on the client’s weaker side to provide support and prevent the client from falling towards their weaker side.

Choice D rationale:

Flexing hips and knees when assisting the client to a standing position is correct. This technique helps the nurse maintain proper body mechanics, reduces the risk of injury, and provides better support to the client during the transfer.

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.