A nurse is providing teaching to a client about reducing the adverse effects of immobility.
Which of the following statements by the client indicates an understanding of the teaching?
"I will perform ankle and knee exercises every hour."
"I will have my partner help me change positions every 4 hours."
"I will remove my antiembolic stockings while I am in bed."
"I will hold my breath when rising from a sitting position."
The Correct Answer is A
A. Regular ankle and knee exercises help prevent muscle atrophy due to immobility.
B. Changing positions every 4 hours is helpful, but more frequent movement is recommended.
C. Antiembolic stockings should be worn when immobile to prevent blood clots.
D. Holding breath during movement doesn't contribute to reducing adverse effects of immobility.
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Related Questions
Correct Answer is C
Explanation
A. Obtaining a random blood glucose daily is important for monitoring glucose levels but might not be specifically related to the introduction of PN in this context.
B. Changing the PN infusion bag every 48 hours might not be universally applicable; the frequency of changing PN bags depends on institutional policies and the stability of the solution being administered.
C. PN with high concentrations of dextrose and fat emulsions typically requires a central venous line for administration to prevent peripheral vein irritation or damage.
D. Administering PN and fat emulsion separately might not be practical as PN usually includes all necessary components in a single infusion.
Correct Answer is B
Explanation
A: The width of the BP cuff should actually be 40% of the client's upper arm circumference, not 50%. Using a cuff that's too large can result in a falsely low reading, while a cuff that's too small can cause a falsely high reading.
B: It is important to recheck the BP in the other arm to compare readings. Differences in blood pressure between arms can indicate vascular issues and provide valuable diagnostic information. Consistency in readings is crucial for accurate diagnosis and treatment.
C: While it may be necessary to monitor the client's BP over time, immediately requesting another nurse to check the BP does not address the immediate concern of the accuracy of the initial reading.
D: Repositioning the client supine may be appropriate if orthostatic hypotension is suspected, but it is not the first action to take. The initial step should be to confirm the accuracy of the reading by checking the other arm.
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