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 B
Explanation
Choice A reason: Opioid analgesics do not typically increase coughing; they may actually suppress cough reflexes.
Choice B reason: Opioid analgesics are known to have a calming effect, which can help reduce anxiety in postoperative patients.
Choice C reason: Opioids can lead to decreased blood pressure, not an increase.
Choice D reason: Opioids typically decrease the respiratory rate, which is a potential side effect that needs to be monitored.
Correct Answer is A
Explanation
Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.
Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.
Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.
Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.
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