When assessing both lower extremities (BLE) of a client who has chronic venous insufficiency, the nurse identifies bilateral stasis dermatitis and an ulcer on the medial surface of the left ankle. To promote effective self-care, which client teaching should the nurse provide?

Apply compression stockings before ambulation.

Soak feet to soften nails before trimming.

Keep legs dependent to promote blood flow.

Medicate inflamed skin areas with an antibiotic ointment.

Answer and Explanation

The Correct Answer is A

Choice A: Applying compression stockings before ambulation is a key aspect of self-care for a client with chronic venous insufficiency. Compression stockings help improve venous return and reduce edema.

Choice B: Soaking feet to soften nails before trimming is not a specific intervention for chronic venous insufficiency and should be done with caution in individuals with open ulcers.

Choice C: Keeping legs dependent to promote blood flow is not advisable in chronic venous insufficiency, as it can worsen venous pooling and edema.

Choice D: Medicating inflamed skin areas with an antibiotic ointment may be part of wound care but does not address the primary intervention of using compression stockings for chronic venous insufficiency.

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Correct Answer is A

Explanation

Choice A: The nurse should determine the pH value of the aspirated fluid to confirm the placement of the NGT. Gastric aspirate typically has an acidic pH (usually below 5), which indicates that the tube is correctly placed in the stomach.

Choice B: Withdrawing the NGT and reinserting it is not necessary if the pH of the aspirate confirms gastric placement.

Choice C: Connecting the NGT to wall suction is not appropriate until placement has been confirmed with a pH test.

Choice D: Sending the fluid specimen to the lab is not the first step in verifying NGT placement. Checking the pH is a more immediate and reliable method.

A. Take a prescribed analgesic an hour prior to breastfeeding. B. Change the infant's position during the next feeding. C. Drink two glasses of water 30 minutes prior to breastfeeding. D. Void and completely empty bladder before each feeding.

Correct Answer is A

Explanation

Choice A: Taking a prescribed analgesic an hour prior to breastfeeding can help alleviate the client's intense cramping while breastfeeding. This approach can provide effective pain relief.

Choice B: Changing the infant's position during the next feeding may or may not address the underlying cause of the client's intense cramping. Pain relief through medication is a more direct intervention.

Choice C: Drinking water before breastfeeding is important for hydration but may not directly address the cramping issue.

Choice D: Voiding and emptying the bladder before each feeding is a routine practice but is not specifically aimed at relieving cramping during breastfeeding.

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When assessing both lower extremities (BLE) of a client who has chronic venous insufficiency, the nurse identifies bilateral stasis dermatitis and an ulcer on the medial surface of the left ankle. To promote effective self-care, which client teaching should the nurse provide?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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