Nokea
A client is discharged after being hospitalized for thrombophlebitis. She will be driving home with her daughter, who lives 2 hours away. During the 2-hour ride, the nurse should advise the client to:
- A. Perform arm circles while riding in the car
- B. Perform ankle pumps and foot range-of-motion exercises
- C. Elevate her legs while riding in the car
- D. Take an ambulance home
Correct Answer: B
Rationale: Ankle pumps and foot range-of-motion exercises during the car ride promote venous return, preventing stasis and recurrent thrombophlebitis. Arm circles are irrelevant, elevating legs is impractical, and an ambulance is unnecessary for a discharged client.
You may also like to solve these questions
The nurse identifies deficient knowledge when the client undergoing induction therapy for leukemia makes which of the following statements?
- A. I will have to pace my activities with rest periods.'
- B. I can't wait to get home to my cat!'
- C. I will use warm saline gargle instead of brushing my teeth.'
- D. I must report a temperature of 100°F.'
Correct Answer: B
Rationale: During leukemia induction therapy, the client is at high risk for infection due to neutropenia. Pets like cats can carry pathogens (e.g., Toxoplasma), and the statement about returning to a cat indicates a knowledge deficit about infection risks. The other statements reflect appropriate self-care measures.
What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy?
- A. Antibiotics will need to be taken for 1 to 2 weeks.
- B. Arm exercises will get rid of the cellulitis.
- C. Ice pack should be applied to the affected area for 20 minute periods to reduce swelling.
- D. The right extremity should be lowered to improve blood flow to the forearm.
Correct Answer: A
Rationale: Antibiotics for 1-2 weeks are the primary treatment for cellulitis, a bacterial infection, to prevent complications in a post-mastectomy client with lymphedema risk.
The nurse should teach the client with an ileal conduit to prevent urine leakage when changing the appliance by using which of the following procedures?
- A. Insert a gauze wick into the stoma.
- B. Close the opening temporarily with a cellophane seal.
- C. Suction the stoma before changing the appliance.
- D. Avoid oral fluids for several hours before changing the appliance.
Correct Answer: A
Rationale: Inserting a gauze wick into the stoma temporarily absorbs urine, preventing leakage during appliance changes, ensuring a dry field for secure adhesion.
The nurse has asked the nursing assistant to ambulate a client with Parkinson's disease. The nurse observes the nursing assistant pulling on the client's arms to get the client to walk forward. The nurse should:
- A. Have the nursing assistant keep a steady pull on the client to promote forward ambulation.
- B. Explain how to overcome a freezing gait by telling the client to march in place.
- C. Assist the nursing assistant with getting the client back in bed.
- D. Give the client a muscle relaxant.
Correct Answer: B
Rationale: Teaching the client to march in place helps overcome freezing gait, a common Parkinson's symptom. Pulling on arms is unsafe, returning to bed is unnecessary, and muscle relaxants are inappropriate.
The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.
- A. The family is coming in to visit.
- B. The client has increased secretions requiring frequent suctioning.
- C. The SpO2 and PO2 have decreased.
- D. The client is tachycardic with drop in blood pressure.
- E. The face has increased skin breakdown and edema.
Correct Answer: C,D,E
Rationale: Decreased SpO2/PO2 (C), tachycardia with hypotension (D), and facial skin breakdown/edema (E) indicate complications requiring a return to supine position. Family visits and suctioning needs are manageable in prone position.