Nokea
Which patient teaching would help to prevent venous stasis?
- A. Dangle legs when sitting.
- B. Avoid crossing the legs at the knee.
- C. Elevate legs when lying in bed or sitting.
- D. Massage extremities to help maintain blood flow.
- E. Wear elastic stockings when ambulating.
Correct Answer: B,C,E
Rationale: Avoid prolonged sitting or standing. Avoid crossing the legs at the knee. Elevate legs when sitting. Wear elastic stockings when ambulatory. Do not massage extremities because of danger of embolization of clots (thrombus breaking off and becoming an embolus).
You may also like to solve these questions
The nurse is aware that which layer is the muscle layer of the heart, which is responsible for the heart's contraction?
- A. endocardium.
- B. pericardium.
- C. mediastinum.
- D. myocardium.
Correct Answer: D
Rationale: The myocardium is the specialized muscle layer that allows the heart to contract.
During a health interview by the home health nurse, which patient report suggests left-sided heart failure?
- A. I have to sleep in my recliner and I have this hacking cough.'
- B. I have no appetite and I have lost $3 \mathrm{lb}$ in the last week.'
- C. I have to urinate every 2 hours, even during the night.'
- D. I go barefoot most of the time because my feet are so hot.'
Correct Answer: A
Rationale: Left ventricular failure is often among the first of signs and symptoms of decreased cardiac output. The second is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough.
The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient makes which statement?
- A. I can ambulate in the hallway with this gadget on.'
- B. I always take off the telemetry device when I shower.'
- C. My EKG is being watched by one of the nurses in CCU on the home unit.'
- D. I am able to sleep just fine with this device on.'
Correct Answer: B
Rationale: Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower.
What is the major cause of cardiac valve disease in past years?
- A. Rheumatic fever
- B. Long history of malnutrition
- C. Drug abuse
- D. Obesity
Correct Answer: A
Rationale: Rheumatic fever, a streptococcal infection, was the major cause of cardiac valve disease in past years.
The nurse assesses pitting edema that can be depressed approximately $4 \mathrm{~mm}$ and refills in 15 seconds. The nurse would document this assessment as:
- A. +1 edema.
- B. +2 edema.
- C. +3 edema.
- D. +4 edema.
Correct Answer: B
Rationale: A +2 edema can be documented if the skin can be depressed $4 \mathrm{~mm}$ and respond within 15 seconds.