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An overweight client taking warfarin (Coumadin) has a nursing diagnosis of ineffective tissue perfusion related to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
- A. Apply lanolin or petroleum jelly to intact skin
- B. Encourage a reduced-calorie, reduced-fat diet
- C. Inspect the involved areas daily for new ulcerations
- D. Instruct the client to limit activities of daily living (ADLs)
- E. Use an electric razor to shave
Correct Answer: B,C,E
Rationale: Rationales: B) A reduced-calorie, reduced-fat diet helps manage weight and reduce atherosclerosis progression, improving arterial blood flow. C) Daily inspection for ulcerations is essential in PVD to detect early skin breakdown due to poor perfusion. E) Using an electric razor minimizes the risk of cuts and bleeding, which is critical for a client on warfarin. A) Applying lanolin or petroleum jelly is not directly related to improving tissue perfusion. D) Limiting ADLs is incorrect, as moderate activity promotes circulation unless contraindicated.
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A client develops lymphedema after a left mastectomy with lymph node dissection. Which of the following should be included in the discharge teaching plan? Select all that apply.
- A. Do not allow blood pressures or blood draws in the affected arm.
- B. Avoid application of sunscreen on the left arm.
- C. Use an electric razor for shaving.
- D. Immobilize the left arm.
- E. Elevate the left arm.
- F. Perform hand pump exercises.
Correct Answer: A,C,E,F
Rationale: Preventing trauma (A, C), elevating the arm (E), and performing exercises (F) reduce lymphedema risk and promote lymphatic drainage. Sunscreen (B) is safe, and immobilization (D) is not recommended.
The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate?
- A. Reassure the client that the nasoenteric tube is functioning.
- B. Assess the client for a rigid abdomen.
- C. Administer an opioid as ordered.
- D. Reposition the client on the left side.
Correct Answer: B
Rationale: Persistent acute pain despite a patent nasoenteric tube suggests a complication like peritonitis, indicated by a rigid abdomen, which requires immediate assessment. Reassurance, opioids, or repositioning may delay addressing a serious issue. CN: Physiological adaptation; CL: Synthesize
A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?
- A. Lean beef.
- B. Air-popped popcorn.
- C. Hot chocolate.
- D. Raw vegetables.
Correct Answer: C
Rationale: Hot chocolate contains caffeine and fat, both of which can relax the lower esophageal sphincter and worsen GERD-related heartburn. The other options are less likely to trigger symptoms.
A client post-ureteroscopy reports burning on urination. The nurse should:
- A. Encourage fluids.
- B. Administer antibiotics.
- C. Apply a heating pad.
- D. Notify the physician.
Correct Answer: A
Rationale: Burning is common post-ureteroscopy; fluids dilute urine, reducing irritation.
A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.