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 B
Explanation
A. Change the tubing set every 72 hr:Continuous enteral feeding tubing sets should generally be changed every 24 hours to reduce the risk of bacterial contamination. Changing every 72 hours is too long and increases infection risk.
B. Aspirate residual volume every 4 hr:Aspiration of residual volume every 4 hours is standard practice when providing continuous enteral feedings. This ensures the client is tolerating the feedings and helps prevent aspiration or overfeeding. Large residual volumes may indicate poor gastric emptying.
C. Flush the tubing with 10 mL of water every 2 hr:The tubing should be flushed with 30 mL of water every 4-6 hours (depending on protocol), not just 10 mL, to maintain tube patency and prevent clogging.
D. Heat the formula to 40.5° C (105° F):Formula should not be heated to such a high temperature. It should be administered at room temperature to avoid discomfort and potential damage to the gastrointestinal tract.
Correct Answer is A
Explanation
A full liquid diet includes all foods that are liquid or will turn to liquid at room temperature or melt at body temperature.
It gives you more nutrition than a clear liquid diet.
Plain yogurt is a food that can be included in a full-liquid diet.
Choice B is not the answer because oatmeal is not part of a full-liquid diet.
Choice C is not the answer because applesauce is not part of a full-liquid diet.
Choice D is not the answer because scrambled eggs are not part of a full-liquid diet.
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