Nokea
The nurse is providing discharge instructions to a client with chronic venous insufficiency. Which recommendation should the nurse include to help prevent complications?
- A. Use a heating pad on the legs
- B. Wear compression stockings
- C. Massage the legs daily
- D. Elevate legs for 10 minutes every hour
Correct Answer: B
Rationale: The correct recommendation for a client with chronic venous insufficiency to prevent complications is to wear compression stockings. Compression stockings help improve venous circulation and prevent the worsening of symptoms. While elevating the legs is also beneficial, the priority intervention in preventing complications is wearing compression stockings. Using a heating pad on the legs can actually worsen the condition by dilating blood vessels, and massaging the legs daily can potentially damage fragile skin in clients with chronic venous insufficiency.
You may also like to solve these questions
After receiving a report on an inpatient acute care unit, which client should the nurse assess first?
- A. Client with pneumonia who has a fever of 101.5°F
- B. Client who underwent knee surgery and needs dressing change
- C. Client with a bowel obstruction due to a volvulus experiencing abdominal rigidity
- D. Client with diabetes requesting insulin
Correct Answer: C
Rationale: The correct answer is C. Abdominal rigidity in a client with a bowel obstruction could indicate peritonitis, a serious complication requiring immediate attention. Volvulus, a twisting of the intestine, can lead to bowel ischemia and necrosis. Clients with pneumonia (choice A) may need assessment and treatment for infection, but it is not as immediately life-threatening as a bowel obstruction. A client who underwent knee surgery (choice B) needing a dressing change can typically wait for assessment compared to a potential surgical emergency. Similarly, a client with diabetes requesting insulin (choice D) may require attention to maintain blood glucose levels, but it is not as urgent as a suspected bowel obstruction with possible peritonitis.
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
- A. A tuna fish sandwich with chips and ice cream
- B. A vegetable salad with croutons and ranch dressing
- C. A grilled chicken breast with steamed vegetables
- D. A peanut butter and jelly sandwich with soda
Correct Answer: C
Rationale: The correct answer is C. Grilled chicken is an excellent source of protein, which is important for wound healing. Choices A, B, and D are less ideal for wound healing. Choice A contains high-fat and high-sugar components like chips and ice cream, which may not support wound healing effectively. Choice B includes croutons and ranch dressing, which may not provide as much protein as needed for wound healing. Choice D with a peanut butter and jelly sandwich and soda lacks a balanced meal with adequate protein to promote wound healing.
A child is brought to the emergency department after ingesting an unknown quantity of acetaminophen. What is the most important action for the nurse to take?
- A. Assess the child's level of consciousness.
- B. Prepare to administer activated charcoal.
- C. Notify the poison control center.
- D. Obtain an order for serum acetaminophen levels.
Correct Answer: D
Rationale: Obtaining serum acetaminophen levels is critical in determining the level of toxicity and guiding treatment. It helps to assess the risk of hepatotoxicity and determine the need for antidotal therapy with N-acetylcysteine. Assessing the child's level of consciousness (Choice A) is important but obtaining serum acetaminophen levels takes precedence as it directly guides the specific treatment required. Activated charcoal (Choice B) is not routinely used in acetaminophen poisoning. While notifying the poison control center (Choice C) is important, obtaining serum acetaminophen levels should be the immediate action to assess the child's condition and guide treatment.
A client receiving continuous ambulatory peritoneal dialysis (CAPD) has lost weight and exhibits increasing edema. What should the nurse prioritize?
- A. Evaluate the patency of the arteriovenous (AV) graft.
- B. Instruct the client to continue a fluid-restricted diet.
- C. Recommend support stockings for venous return.
- D. Monitor the client's serum albumin levels.
Correct Answer: A
Rationale: In a client receiving continuous ambulatory peritoneal dialysis (CAPD) who has lost weight and exhibits increasing edema, the nurse should prioritize evaluating the patency of the arteriovenous (AV) graft. This assessment is crucial to determine if hemodialysis can be resumed, addressing the client's presenting issues effectively. Instructing the client to continue a fluid-restricted diet (choice B) may not address the underlying issue related to the CAPD. Recommending support stockings for venous return (choice C) is not directly relevant to the situation described. Monitoring the client's serum albumin levels (choice D) may be important but does not directly address the immediate concern of weight loss and increasing edema in a CAPD client.
A client is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?
- A. Is allergic to shellfish
- B. Has a history of smoking
- C. Takes metformin for type 2 diabetes mellitus
- D. Has hypertension controlled with medication
Correct Answer: A
Rationale: An allergy to shellfish often indicates an allergy to iodine, which is used in contrast dyes for CT scans. This poses a significant risk of an allergic reaction during the procedure. The nurse must ensure appropriate precautions or alternative imaging are considered. Choices B, C, and D are not directly contraindicated for a CT scan with contrast. Smoking history, metformin use, and controlled hypertension do not typically impact the safety or feasibility of the procedure.