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

The patient should eat a diet high in protein and vitamins A and C.

The patient should keep their legs elevated when sitting or lying down.

The patient should maintain as much bed rest as possible.

The patient should inspect their ankles daily for areas of darkening skin.

The patient should apply intermittent cold compresses four times daily.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale
A diet high in protein and vitamins A and C can help promote wound healing. Protein is essential for tissue repair, and vitamins A and C play crucial roles in wound healing and immune function.
Choice B rationale
Keeping legs elevated when sitting or lying down can help reduce swelling and improve blood circulation, which is beneficial for healing venous leg ulcers.
Choice C rationale
Maintaining as much bed rest as possible is not typically recommended for patients with venous leg ulcers. Physical activity and movement can help improve blood circulation, which is beneficial for healing venous leg ulcers.
Choice D rationale
Inspecting ankles daily for areas of darkening skin can help detect early signs of worsening venous leg ulcers. Early detection and treatment can prevent complications and promote healing.
Choice E rationale
Applying intermittent cold compresses four times daily is not typically recommended for venous leg ulcers. Cold compresses can constrict blood vessels and reduce blood flow to the area, which may hinder the healing process.

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Correct Answer is D

Explanation

Choice A rationale
Cold and dry skin can be a symptom of hypothyroidism, but it’s not typically a sign that requires immediate action.
Choice B rationale
Facial puffiness and periorbital edema can be symptoms of hypothyroidism, but they’re not typically signs that require immediate action.
Choice C rationale
A hematocrit of 30% (0.30 volume fraction) is lower than the normal range, indicating anemia. While this is a concern and should be addressed, it’s not typically a sign that requires immediate action in the context of hypothyroidism.
Choice D rationale
A further decline in the level of consciousness can be a serious sign of deteriorating health in a client with hypothyroidism and should be acted upon immediately.

A. Blood pH level B. Hematocrit C. White blood cell (WBC) count D. Platelet count

Correct Answer is C

Explanation

Choice A rationale
Blood pH level is a measure of the acidity or alkalinity of the blood. While it’s an important measure in many medical situations, it’s not directly related to the presence of purulent drainage at a burn wound site.
Choice B rationale
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.
Choice C rationale
The White Blood Cell (WBC) count is a key indicator of infection or inflammation in the body. An elevated WBC count can indicate an infection, which could be the cause of the purulent drainage observed at the burn wound site.
Choice D rationale
Platelet count is a measure of the number of platelets in the blood. Platelets are involved in clotting and wound healing, but they do not directly indicate the presence of an infection that could cause purulent drainage.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?

Correct Answer is D

Explanation

A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient’s laboratory values should the nurse review?

Correct Answer is C

Explanation

The nurse is assessing a patient’s understanding of the DASH (Dietary Approaches to Stop Hypertension) diet. Which patient behavior suggests adherence to this diet?

While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

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