The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

Eat a diet that is high in protein and vitamins A and C.

Maintain bed rest as much as possible.

Keep legs elevated when sitting or lying down.

Inspect ankles daily for areas of darkening skin.

Apply intermittent cold compresses four times daily.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale
Eating a diet that is high in protein and vitamins A and C is beneficial for wound healing. Protein is essential for tissue repair, while vitamins A and C play a crucial role in collagen synthesis, which is vital for wound healing.
Choice B rationale
Maintaining bed rest as much as possible is not the best advice for a patient with venous leg ulcers. Mobility improves blood circulation, which can aid in the healing of the ulcers.
Choice C rationale
Keeping legs elevated when sitting or lying down can help reduce swelling and improve blood flow, which can promote healing of the ulcers.
Choice D rationale
Inspecting ankles daily for areas of darkening skin is important as it can help in early detection of any potential complications or worsening of the condition.
Choice E rationale
Applying intermittent cold compresses four times daily is not typically recommended for venous leg ulcers. The standard treatment involves cleaning and dressing the wound, using compression therapy, and in some cases, taking prescribed medications.

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Correct Answer is D

Explanation

Choice A rationale
Brown, rough, greasy, wart-like papules on the face are not typically associated with overexposure to PUVA treatment. These symptoms could be indicative of a different skin condition.
Choice B rationale
Thick skin plaques topped by silvery-white scales are characteristic of psoriasis vulgaris, not overexposure to PUVA treatment. PUVA is used to treat these symptoms, not cause them.
Choice C rationale
Needing sunglasses because sunlight hurts the eyes is not a typical sign of overexposure to PUVA treatment. This could be a sign of a different issue, such as an eye condition or side effect from a different medication.
Choice D rationale
Tenderness upon palpation and generalized erythema are signs of overexposure to PUVA treatment. If a patient is overexposed to PUVA, they may experience a burning sensation, discomfort, and redness at the treatment site.

A. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter. B. Medicate for pain and monitor vital signs according to protocol. C. Encourage the client to splint the incision with a pillow to cough and deep breathe. D. Administer intravenous fluid bolus as prescribed by the healthcare provider.

Correct Answer is A

Explanation

Choice A rationale
Applying oxygen at 10 L via non-rebreather mask and monitoring pulse oximeter is the most important intervention for a patient in the post-anesthesia care unit (PACU) with a heart rate of 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute.
These vital signs suggest that the patient may be experiencing hypoxia or respiratory distress, conditions that require immediate intervention.
Choice B rationale
Medicating for pain and monitoring vital signs according to protocol is important in the PACU, but it is not the most critical intervention in this scenario. The patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.
Choice C rationale
Encouraging the client to splint the incision with a pillow to cough and deep breathe is a common postoperative intervention to promote lung expansion and prevent atelectasis and pneumonia. However, in this scenario, the patient’s vital signs suggest a more immediate respiratory issue that requires prompt intervention.
Choice D rationale
Administering an intravenous fluid bolus as prescribed by the healthcare provider can be an appropriate intervention for certain conditions in the PACU, such as hypotension. However, in this scenario, the patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.

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The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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