The nurse is providing care for a client diagnosed with post-thrombotic syndrome who has a venous stasis ulcer. Which instructions should be given prior to discharge? (Select all that apply)

Increase intake of proteins, take vitamin C and zinc

Use care when walking to avoid bumping your limb

Cleanse the ulcer with soap and water

Apply cortisone cream to decrease itching

Put on compression stockings before getting out of bed

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale

Proteins, vitamin C, and zinc are essential for wound healing. Proteins are the building blocks for body tissue, and zinc plays a role in protein synthesis. Vitamin C is needed for the formation of collagen, a protein used to make skin, scar tissue, and blood vessels.

Choice B rationale

Care should be taken when walking to avoid bumping the limb. Any trauma to the affected limb could potentially worsen the condition or delay healing.

Choice C rationale

Cleaning the ulcer with soap and water may not be the best option. Soap can be irritating to the skin and may delay healing. Instead, the ulcer should be cleaned as per healthcare provider’s instructions.

Choice D rationale

Cortisone cream is not typically used for venous stasis ulcers. It can thin the skin and delay healing.

Choice E rationale

Compression stockings are often recommended for patients with post-thrombotic syndrome. They can help reduce swelling and improve blood flow, which can promote healing of the venous stasis ulcer.

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Correct Answer is C

No explanation

A. Smaller doses of both drugs can be used with this method. B. This combination facilitates the thrombolysis more quickly. C. The heparin provides anticoagulation until the warfarin becomes effective. D. This combination provides immediate anticoagulation.

Correct Answer is C

Explanation

Choice A rationale

While it might seem that smaller doses of both drugs could be used when they are prescribed together, this is not the primary reason for using heparin and warfarin together. Both drugs have different mechanisms of action and are used for their unique therapeutic effects.

Choice B rationale

The combination of heparin and warfarin does not facilitate thrombolysis more quickly. Thrombolysis is the process of breaking down clots, and while these medications can prevent the formation of new clots, they do not actively break down existing ones.

Choice C rationale

Heparin and warfarin are often used together in the treatment of thrombophlebitis because they provide different benefits. Heparin acts quickly to prevent further clotting and allows the body to naturally break down existing clots. Warfarin, on the other hand, takes several days to become effective. Therefore, heparin is used to provide immediate anticoagulation until the warfarin becomes effective.

Choice D rationale

While it’s true that the combination of heparin and warfarin provides immediate anticoagulation, this is primarily due to the action of heparin. Warfarin takes several days to become effective, so it does not contribute to the immediate anticoagulant effect.

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The nurse is providing care for a client diagnosed with post-thrombotic syndrome who has a venous stasis ulcer. Which instructions should be given prior to discharge? (Select all that apply)

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Choice E rationale

Nursing Test Bank

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Correct Answer is C

A client is receiving heparin sodium 1000 units per hour via an infusion and warfarin sodium 2.5 mg PO for thrombophlebitis in the left leg. The nurse educates the client that heparin and warfarin are prescribed together because:

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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