A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?
"I will wear stockings with elastic tops.”.
"I will avoid crossing my legs at the knees.”.
"I will not go barefoot.”.
"I will use a thermometer to check the temperature of my bath water.”. .
The Correct Answer is A
The correct answer is Choice A: "I will wear stockings with elastic tops."
Choice A rationale:
Wearing stockings with elastic tops can constrict blood flow in the legs, which is counterproductive for individuals with peripheral vascular disease. Compression stockings specifically designed for PVD are recommended, but these should be properly fitted and used according to medical advice.
Choice B rationale:
Avoiding crossing the legs at the knees is appropriate for individuals with PVD, as this can impede blood flow and worsen symptoms.
Choice C rationale:
Not going barefoot is important for clients with PVD, as it reduces the risk of injury and infection, which can be more serious due to compromised circulation.
Choice D rationale:
Using a thermometer to check the temperature of bath water is crucial for clients with PVD to avoid burns, since they may have decreased sensation in their extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Crackles in lung bases Crackles in the lung bases are often indicative of fluid accumulation in the lungs, which can occur in conditions like heart failure. These crackles are discontinuous and sound like "fine rales.”. They can be heard during inspiration and expiration.
Choice B rationale:
Periorbital edema Periorbital edema, or swelling around the eyes, can be a sign of fluid volume overload, especially in the context of an older adult receiving IV therapy. It suggests that excess fluid is accumulating in the body.
Choice D rationale:
Bounding radial pulse A bounding radial pulse is a sign of increased stroke volume and can occur when the heart is working harder to pump the increased blood volume associated with fluid overload.
Choice C rationale:
Swelling at the IV site Swelling at the IV site can be a local reaction and may not necessarily indicate fluid volume overload unless it is associated with other systemic signs.
Choice E rationale:
Flat neck veins when supine Flat neck veins when the client is supine are not typically associated with fluid volume overload. In fact, flat neck veins are more characteristic of hypovolemia. Now, let's address the final question.
Correct Answer is C
Explanation
The correct answer is C.
Choice A: Oxygen saturation of 95% The normal oxygen saturation level is between 95% and 100%. An oxygen saturation of 95% is within the normal range, so the nurse would not need to withhold furosemide for this reason.
Choice B: Serum sodium level of 140 mEq/L The normal serum sodium levels range from 135 to 145 mEq/L. A serum sodium level of 140 mEq/L is within the normal range, so the nurse would not need to withhold furosemide for this reason.
Choice C: Blood pressure of 80/40 mm Hg Furosemide is a potent diuretic that can lead to a significant depletion of electrolytes, which may lead to side effects such as muscle cramps and an irregular heartbeat. Low blood pressure (hypotension) is a potential side effect of furosemide. Normal blood pressure for adults is typically around 120/80 mm Hg. A blood pressure reading of 80/40 mm Hg is considerably lower than the normal range, indicating hypotension.
Choice D: Serum potassium level of 4.8 mEq/L The normal serum potassium levels range from 3.6 to 5.2 mEq/L. A serum potassium level of 4.8 mEq/L is within the normal range, so the nurse would not need to withhold furosemide for this reason.
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