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
The nurse should first auscultate the client’s bowel sounds.
This will provide important information about the client’s gastrointestinal function and can help determine the cause of the client’s symptoms.
Choice A is wrong because while offering pain medication may provide temporary relief, it does not address the underlying cause of the client’s symptoms.
Choice C is wrong because palpating the abdomen before auscultating bowel sounds can alter the bowel sounds and make it more difficult to accurately assess the client’s condition.
Choice D is wrong because administering an antiemetic may provide temporary relief from nausea and vomiting, but it does not address the underlying cause of the client’s symptoms.
Correct Answer is D
Explanation
When a client is restrained to each extremity, it is important for the nurse to assess the client’s peripheral pulses first to ensure that circulation is not compromised.
Choice A, Elimination needs, is important but not the first priority in this situation.
Choice B, Comfort level, is also important but not the first priority in this situation.
Choice C, Skin integrity, is important but not the first priority in this situation.
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