A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?
Check the capillary refill every 4 hrs
Compare the pedal pulses every 4 hrs
The Correct Answer is B
A. Check the capillary refill every 4 hrs Incorrect
The nurse should check capillary refill distally every 4 hr for a client whops elastic bandages on their lower extremities.
B. Compare the pedal pulses every 4 hrs CORRECT
The nurse should compare the pedal pulses bilaterally every week to check for adequate circulation for a client who has elastic bandages on their
lower extremities.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. Provide an artificial voice box - This is not typically used for clients with aphasia as it does not address the communication barriers they face.
B. Avoid using facial gestures - Facial gestures can be a helpful non-verbal communication tool, especially for clients with aphasia, so avoiding them is not beneficial.
C. Speak to the client in a louder voice - Aphasia affects language processing, not hearing, so increasing volume does not aid in understanding.
D. Ask the client close-ended questions - This allows the client to respond with 'yes' or 'no', or other simple answers, which can be easier for someone with aphasia.
Correct Answer is ["B","D","E"]
Explanation
A: A full bounding pulse is a sign of increased fluid volume or fluid overload, not fluid volume deficit.
B: Cool extremities can be an indication of decreased peripheral perfusion, which may occur in fluid volume deficit.
C: Moist crackles in the lungs are an indication of fluid volume excess or pulmonary congestion, not fluid volume deficit.
D: Orthostatic hypotension, which is a drop in blood pressure when changing from lying to standing, can be a sign of fluid volume deficit due to inadequate blood volume.
E: Flat neck veins are an indication of decreased venous return and can occur in fluid volume deficit.
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