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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Allen's test is a procedure used to assess the patency of the ulnar artery and the collateral circulation of the hand. It is performed to determine the adequacy of collateral circulation before obtaining arterial blood gases from the radial artery. The test helps ensure that the ulnar artery is functioning properly and can supply blood to the hand if the radial artery is used for blood sampling or other invasive procedures.
The test involves occluding both the ulnar and radial arteries while the patient clenches their fist. The nurse then releases pressure on the ulnar artery while maintaining occlusion of the radial artery. The hand should quickly regain normal coloration, indicating adequate collateral circulation.
It's important to note that the Allen's test is specific to the assessment of collateral circulation in the hand and is not used for other purposes such as assessing deep vein thrombosis, cardiac output calculation, or obtaining pulmonary artery pressures.
Correct Answer is ["A","B","C","D","E"]
Explanation
It is important to assess the child's vital signs, including oxygen saturation (SaO2), to ensure their stability and identify any signs of respiratory distress or other abnormalities that may impact medication administration.
Prior to administering any medication, it is crucial to verify if the child has any known allergies to medications. This information is essential for ensuring the safety of the child and preventing any potential allergic reactions.
Before administering pain medication, the nurse must verify that the prescribed dosage is appropriate for the child's age, weight, and condition. Ensuring the correct dosage helps prevent medication errors and potential adverse effects.
It is important to use a validated pain assessment tool that is appropriate for the child's age and cognitive abilities. This allows for a comprehensive and accurate assessment of the child's pain level, helping guide appropriate pain management interventions.
Considering the child has cognitive and speech delays, the input from the parent regarding the child's pain is valuable. The nurse should assess and consider the parent's report of the child's pain in conjunction with other assessment findings to ensure effective pain management.
Subjective pain assessment is mentioned as a finding but may not require immediate action, as it needs to be combined with other assessment data for a comprehensive evaluation.
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