A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching?
Maintain bed rest for 48 hr.
Keep legs in a dependent position.
Wrap the leg with an elastic bandage.
Implement a sodium-restricted diet.
The Correct Answer is C
The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.
The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.
The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.
The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The face is incorrect: Facial skin colour can vary for many reasons, but it may not be the best indicator of jaundice in individuals with dark skin.
Choice B reason
Shoulders is incorrect: The shoulders are not typically indicative of jaundice.
Choice C reason:
Palm of the hands is incorrect: While the palm of the hands can sometimes show yellowing in cases of jaundice, it is less reliable than observing the sclera.
Choice D reason:
Sclera is the best location. In individuals with darker skin tones, yellowish discoloration of the skin due to jaundice can be more challenging to detect. However, the sclera of the eyes can still show noticeable yellowing, making it a reliable location for assessing jaundice in individuals with both light and dark skin.
Correct Answer is D
Explanation
The correct answer is choice d. Measure the client’s abdominal girth daily.
Choice A rationale:
Positioning the client supine with legs elevated is not recommended for managing ascites. This position does not help in reducing fluid accumulation in the abdomen and may worsen respiratory issues.
Choice B rationale:
Keeping the client’s daily protein intake below 0.8 g/kg is not typically recommended for clients with cirrhosis and ascites. Adequate protein intake is necessary to prevent muscle wasting and maintain nutritional status.
Choice C rationale:
Restricting the client’s sodium intake to 2 g not 3g per day is a common intervention for managing ascites, but it is usually more restrictive, often around 2 g per day, to effectively reduce fluid retention.
Choice D rationale:
Measuring the client’s abdominal girth daily is essential for monitoring the progression of ascites. It helps in assessing the effectiveness of treatment and detecting any worsening of the condition.
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