A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching?
Maintain bed rest for 48 hr.
Keep legs in a dependent position.
Wrap the leg with an elastic bandage.
Implement a sodium-restricted diet.
The Correct Answer is C
The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.
The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.
The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.
The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.
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Correct Answer is B
Explanation
The correct answer is B. Performing sponge baths until the baby's umbilical cord falls off is a recommended practice to prevent infection and promote healing of the cord stump. The bath water should be warm but not hot, around 85 to 90 degrees Fahrenheit. Talcum powder can irritate the baby's skin and lungs and should be avoided. Alkaline soap can dry out the baby's skin and should be replaced with a mild, pH-balanced cleanser.
Correct Answer is D
Explanation
The correct answer is D.
Verify the medication three times with the medication administration record. The nurse should follow the six rights of medication administration: right client, right drug, right dose, right route, right time, and right documentation. To ensure the right drug and dose, the nurse should check the medication label against the medication administration record (MAR) three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.
The nurse should also use two identifiers (such as name and date of birth) to verify the right client. The nurse should document medication administration after giving the medication, not before, to avoid errors and ensure accuracy. The nurse should administer time-critical medications within 30 minutes before or after the scheduled time, not 60 minutes.
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