A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
A
B
C
D
The Correct Answer is D
Rationale:
A. This area is the lateral side of the the heel and is more commonly affected by arterial ulcers or pressure injuries. It is not the typical location for ulcers caused by venous insufficiency.
B. This area is the area on the tip of toes and is not a typical site for venous ulcers. Ulcers in this location are commonly arterial or diabetic ulcers.
C. This area is the area on the sole of the feet at the base of the big toe and is not a typical site for venous ulcers.
D. This area is the medial malleolus, just above the inner ankle, which is the most common site for venous ulcers. Chronic venous insufficiency leads to venous stasis and increased pressure in this region, causing skin breakdown and ulceration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Rationale:
A. Wear a protective gown when suctioning the client's airway: While wearing appropriate personal protective equipment protects the nurse from contamination, it does not directly reduce the client’s risk for ventilator-associated pneumonia.
B. Monitor for oral secretions every 2 hr: Regular assessment for and removal of oral secretions reduces the risk of aspiration, which is a key contributor to the development of ventilator-associated pneumonia.
C. Provide oral care every 2 hr: Frequent oral hygiene decreases the colonization of bacteria in the oropharynx, thereby reducing the risk of these organisms being aspirated into the lungs and causing infection.
D. Maintain the client in a supine position: Keeping the client supine increases the risk of aspiration. To prevent VAP, the head of the bed should typically be elevated 30 to 45 degrees unless contraindicated.
E. Assess the client daily for readiness of extubation: Daily evaluation for weaning from the ventilator reduces the duration of mechanical ventilation, which directly lowers the risk of developing ventilator-associated pneumonia.
Correct Answer is C
Explanation
Rationale:
A. "Take a dose of loperamide each morning.": Loperamide is an antidiarrheal medication and is not appropriate for clients with constipation-predominant IBS (IBS-C). Using loperamide in these clients could worsen constipation.
B. "Increase your fluid intake to 1,000 milliliters per day.": A daily fluid intake of 1,000 milliliters (1 liter) is typically insufficient. Adequate hydration is essential for managing constipation, and clients are generally encouraged to consume at least 6 to 8 glasses (approximately 1.5 to 2 liters) of water daily to help soften stools and promote regular bowel movements.
C. "Take psyllium in the evening.": Psyllium is a soluble fiber supplement that can help alleviate constipation by increasing stool bulk and promoting bowel movements. Taking psyllium in the evening is appropriate, but it is crucial to take it with a full glass of water and maintain adequate hydration throughout the day to prevent potential side effects like bloating or gas.
D. "Consume a diet that is low in protein.": There is no specific recommendation for a low-protein diet in managing IBS-C. Dietary modifications for IBS-C typically focus on increasing soluble fiber intake and reducing fermentable carbohydrates (FODMAPs) rather than altering protein consumption.
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