A nurse in a clinic is teaching preventative measures with a female client who has a history of deep-vein thrombosis. Which of the following statements should the nurse include in the teaching?
"Sit with your legs in a dependent position when in a chair."
"Prevent dehydration by drinking at least 2.5 liters fluids each day."
"Massage your calves after sitting for 2 hours."
"Roll stretchy nylon stockings down to the upper part of your calves."
The Correct Answer is B
A) "Sit with your legs in a dependent position when in a chair."
Sitting with legs in a dependent position can decrease blood flow and increase the risk of clot formation. It's important to elevate the legs when sitting to promote venous return and reduce the risk of deep-vein thrombosis (DVT).
B) "Prevent dehydration by drinking at least 2.5 liters fluids each day."
Staying well-hydrated helps maintain good blood circulation and prevents blood from becoming too viscous, reducing the risk of clot formation. Adequate fluid intake is crucial in preventing DVT.
C) "Massage your calves after sitting for 2 hours."
Massaging the calves is not recommended for someone with a history of DVT, as it may dislodge a clot. Instead, clients should be encouraged to move or stretch their legs regularly to improve circulation.
D) "Roll stretchy nylon stockings down to the upper part of your calves."
Proper use of compression stockings involves wearing them as prescribed, which typically means keeping them fully extended to ensure consistent pressure along the leg. Rolling them down can create a tourniquet effect and is not recommended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "You should remain on a clear liquid diet for 1 week after surgery.": After a laparoscopic cholecystectomy, clients do not need to remain on a clear liquid diet for a week. They can usually progress to a regular diet as tolerated, starting with light meals and avoiding fatty, greasy foods initially to prevent discomfort.
B) "Avoid showering for 1 week after surgery.": Clients are typically allowed to shower within a day or two after surgery, as long as they avoid soaking the incisions in water and follow the healthcare provider's instructions for incision care. Avoiding showering for a week is generally unnecessary and may hinder hygiene.
C) "Cleanse the incision sites with hydrogen peroxide.": Hydrogen peroxide can delay wound healing and is not recommended for routine incision care. The nurse should advise the client to cleanse the incision sites with mild soap and water and pat them dry.
D) "Apply heat to the right shoulder for pain.": Applying heat to the right shoulder can help relieve referred pain often experienced after a laparoscopic cholecystectomy due to residual gas used during the procedure. This is a common and effective method for managing postoperative discomfort.
Correct Answer is D
Explanation
A) Limit crossing your legs at your knees to 30 minutes at a time: Crossing the legs at the knees can restrict blood flow and increase venous pressure, which is detrimental to clients with venous insufficiency. It's generally advised to avoid crossing legs altogether rather than limiting it to 30 minutes.
B) Elevate the head of the bed when sleeping at night: Elevating the head of the bed does not significantly aid in improving venous return from the legs. Elevating the legs instead helps reduce venous pressure and promotes better circulation, which is more beneficial for venous insufficiency.
C) Wash your graduated compression stockings in the washing machine: Washing compression stockings in a washing machine can damage their elasticity and effectiveness. It's better to hand wash them and let them air dry to maintain their compression properties.
D) Put on your graduated compression stockings before getting out of bed: Putting on compression stockings before getting out of bed helps to prevent blood from pooling in the legs. This maximizes their effectiveness in reducing edema and promoting venous return throughout the day.
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