Nokea
The nurse is instructing a client who is at risk for peripheral vascular disease how to use knee-length elastic stockings (support hose). The teaching plan should include which of the following? Check all that apply.
- A. Apply the elastic stockings in the morning
- B. Remove the stockings if swelling occurs
- C. Apply the stockings while in bed
- D. Once the stockings have been pulled over the calf, roll the remaining stocking down to make a cuff
- E. Keep the stockings in place for 48 hours and reapply using a clean pair of stockings
Correct Answer: A,C
Rationale: Rationales: A) Applying elastic stockings in the morning before edema worsens helps promote venous return. C) Applying them while in bed (before standing) minimizes swelling and eases application. B) Removing stockings for swelling requires medical evaluation, not automatic removal. D) Rolling down to form a cuff creates pressure points, impairing circulation. E) Stockings should be removed daily for skin inspection and hygiene, not kept on for 48 hours.
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What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate (Robinul)?
- A. Increased heart rate.
- B. Increased respiratory rate.
- C. Decreased secretions.
- D. Decreased amnesia.
Correct Answer: C
Rationale: Glycopyrrolate is an anticholinergic that reduces salivary and respiratory secretions, improving airway management during surgery.
Which medication requires monitoring for a client with Parkinson's disease?
- A. Antihypertensives.
- B. Levodopa.
- C. Antidepressants.
- D. Antihistamines.
Correct Answer: B
Rationale: Levodopa requires monitoring for efficacy and side effects, as it is a primary treatment for Parkinson's symptoms.
The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should:
- A. Apply a half-leg pneumatic compression device
- B. Suggest the client contact her physician
- C. Assess the client for foot ulcers
- D. Encourage the client to avoid standing in one position for long periods of time
Correct Answer: D
Rationale: Distended, tortuous veins suggest varic varicose veins. Avoiding prolonged standing reduces venous pooling and symptom progression. Applying compression devices requires a prescription, contacting a physician is premature, and foot ulcers are not indicated by the description.
A client with an ileal conduit asks how to reduce pouch odor. The nurse suggests:
- A. Avoiding broccoli.
- B. Using bleach to clean the pouch.
- C. Drinking less water.
- D. Applying powder to the stoma.
Correct Answer: A
Rationale: Odor-producing foods like broccoli should be avoided to minimize pouch odor.
The nurse is teaching a caregiver how to administer an injection of enoxaparin. Which statement, if made by the caregiver, would require further teaching?
- A. "I will give this injection in the abdomen."
- B. "I should give this injection at a 30 degree angle."
- C. "Acetaminophen is safe while taking this medication for any aches or pains."
- D. "A soft toothbrush should be used while taking this medicine."
Correct Answer: B
Rationale: Enoxaparin is administered subcutaneously at a 90-degree angle, not 30 degrees, to ensure proper absorption.