The nurse is caring for a patient with venous stasis ulcers. What actions should the nurse take?
Instruct the patient to wear constrictive clothing.
Encourage the patient to keep legs in a dependent position.
Encourage frequent ambulation.
Apply compression stockings.
The Correct Answer is D
Choice A reason: Instructing the patient to wear constrictive clothing is incorrect, as it can worsen venous stasis ulcers by impeding blood flow.
Choice B reason: Encouraging the patient to keep legs in a dependent position is not recommended, as elevation helps in reducing venous pressure.
Choice C reason: Frequent ambulation is encouraged to promote blood circulation and prevent stasis.
Choice D reason: Applying compression stockings is a standard care practice to help reduce venous pressure and prevent fluid from pooling in the legs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The use of a heating pad on the operative site is not typically recommended immediately post-surgery due to the risk of bleeding and swelling.
Choice B reason: Patients are encouraged to mobilize as soon as possible after surgery to prevent complications such as deep vein thrombosis and pulmonary embolism.
Choice C reason: The use of a CPM machine is common after total hip replacement surgery to help restore joint function and prevent stiffness.
Choice D reason: Using a special soap the evening before surgery is part of the preoperative preparation to reduce the risk of infection.
Correct Answer is C
Explanation
Choice A reason: Vomiting can be a sign of a transfusion reaction, but it is not as specific as low back pain for an acute hemolytic reaction.
Choice B reason: Urticaria, or hives, may indicate an allergic reaction but is not specific to an acute hemolytic reaction.
Choice C reason: Low back pain is a classic symptom of an acute hemolytic reaction, which is a serious and potentially life-threatening condition that requires immediate attention.
Choice D reason: Pulmonary congestion may occur in various conditions and is not the most specific indicator of an acute hemolytic reaction.
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