A nurse is providing teaching to a client who is at risk for thrombus formation.
Which of the following statements made by the client indicates an understanding of the teaching?
"I will keep my legs crossed while sitting."
"I will perform leg exercises once every 4 hours while I am awake."
"I should limit the time that I spend sitting in a chair."
"I should massage my legs when they hurt.".
The Correct Answer is C
“I should limit the time that I spend sitting in a chair.” This is important because sitting for long periods of time can increase the risk of thrombus formation.
Choice A is wrong because crossing the legs while sitting can impede blood flow and increase the risk of thrombus formation.
Choice B is wrong because leg exercises should be performed more frequently than once every 4 hours while awake.
Choice D is wrong because massaging the legs when they hurt can dislodge a thrombus and cause it to travel to other parts of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The first two actions the nurse should take are to review the client’s medical history and assess for symptoms.
This can help determine if further testing or treatment is necessary.
Choice A is wrong because the test results are negative, so initiating treatment for TB is not necessary.
Choice B is wrong because repeating the tests may not provide any additional information.
Choice D is wrong because educating the client about TB prevention and management may not be necessary if the client does not have TB.
Correct Answer is D
Explanation
Step 1: Calculate the total fluid intake. The client received 0.9% sodium chloride 600 mL IV infusion and cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus. So, the total fluid intake is 600 mL + 100 mL = 700 mL.
Step 2: Calculate the total fluid output. The client had 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. So, the total fluid output is 200 mL + 40 mL + 20 mL = 260 mL.
Step 3: Calculate the net fluid intake. The net fluid intake is the total fluid intake minus the total fluid output. So, the net fluid intake is 700 mL - 260 mL = 440 mL.
Therefore, the nurse should record the net fluid intake as 440 mL.
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