The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)

Avoid prolonged standing or sitting.

Continue wearing compression stockings.

Cross legs at knee but not at ankle.

Use recliner for long periods of sitting.

Maintain the bed flat while sleeping.

Answer and Explanation

Correct Answer : A,B,D

A. Prolonged standing or sitting can worsen venous insufficiency and increase the risk of blood pooling in the legs. Encouraging the client to move around and avoid prolonged periods of immobility can help improve circulation.

B. Compression stockings help improve blood flow by applying pressure to the legs, reducing swelling and preventing blood from pooling. The client should be instructed to continue wearing them as prescribed by their healthcare provider.

C.Crossing the legs can impede blood flow and should be avoided altogether.

D. Sitting for extended periods can also contribute to blood pooling. Using a recliner allows the client to elevate their legs, promoting better circulation and reducing the risk of complications. The nurse should recommend using a recliner when sitting for long periods of time.

E. Elevating legs during sleep is generally advised to reduce venous pressure.

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Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: Ice application induces vasoconstriction, which reduces swelling but does not evert inverted nipples. This action does not address the primary issue of nipple inversion preventing adequate latch.

Choice B rationale: Breast pump use creates negative pressure, drawing out the nipple. This eversion facilitates latching by providing a more prominent nipple for the infant's oral cavity to grasp effectively.

Choice C rationale: Supplemental formula feedings provide nutrition, but do not resolve the latching difficulty caused by inverted nipples. This can interfere with the establishment of the mother's milk supply.

Choice D rationale: Breast shields can aid latching, but they are most effective when used in conjunction with nipple eversion techniques. They do not directly address the underlying problem of inverted nipples.

A. Coarse breath sounds. B. Rust colored sputum. C. Unexplained fatigue. D. Clubbed fingernails.

Correct Answer is A

Explanation

The client's history of lung cancer, persistent hoarseness, chronic cough, and labored respirations when speaking indicate potential respiratory complications. Coarse breath sounds may suggest the presence of airway obstruction or fluid accumulation in the lungs, which can be indicative of a worsening condition.

The nurse should intervene promptly by assessing the client's respiratory status further, providing appropriate respiratory support, and notifying the healthcare provider for further evaluation and intervention.

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The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is B

Explanation

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

Correct Answer is A

Explanation

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