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
When administering multiple medications via an NG tube, each medication should be prepared separately by crushing (if appropriate) and diluting it with sterile water. This method helps prevent drug interactions, ensures that medications are adequately dissolved, and minimizes the risk of clogging the tube.
Choice B is wrong because medications should not be combined with the formula in the feeding bag.
Choice C is wrong because the NG tube should be flushed with at least 15 to 30 mL of water before and after drug delivery.
Choice D is wrong because each medication should be administered separately when it is being given at the same time.
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