A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?
"Apply ice packs to your legs."
"Place your legs in a dependent position while in bed."
"Remain on bed rest."
"Use elastic stockings."
The Correct Answer is D
Using elastic stockings is an effective way to improve venous return and prevent edema, stasis, and ulceration in clients who have venous insufficiency. The stockings should be applied before getting out of bed and worn throughout the day.
"Apply ice packs to your legs." is not appropriate, as ice packs can cause vasoconstriction and impair blood flow to the legs, worsening the condition.
"Place your legs in a dependent position while in bed." is not advisable, as dependent position can increase venous pressure and fluid accumulation in the legs, leading to edema, pain, and skin breakdown
"Remain on bed rest." is not necessary, as bed rest can reduce muscle contraction and impair venous return. The client should be encouraged to perform regular exercise, such as walking, to enhance circulation and prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A headache is a common and expected adverse effect of nitroglycerin, due to its vasodilating action. The client can take an over-the-counter analgesic to relieve the headache, unless contraindicated.
"A headache is an indication of an allergy to the medication." is not correct, as a headache is not a sign of an allergic reaction to nitroglycerin. An allergic reaction would manifest as rash, itching, swelling, or difficulty breathing.
"A headache indicates tolerance to the medication." is not accurate, as a headache does not indicate tolerance to nitroglycerin. Tolerance would manifest as reduced or absent relief from anginal pain.
"A headache is likely due to the anxiety about the chest pain." is not plausible, as a headache is not likely due to the anxiety about the chest pain. Anxiety would manifest as nervousness, restlessness, palpitations, or sweating.
Correct Answer is B
Explanation
Frothy sputum is a sign of left-sided heart failure, due to the pulmonary congestion and impaired gas exchange. The sputum may be pink-tinged or blood-streaked, indicating pulmonary edema.
a. Dependent edema is more likely to be seen in clients who have right-sided heart failure, due to the increased venous pressure and fluid retention. The edema is usually symmetrical and affects the lower extremities, abdomen, and sometimes the face.
c. Nocturnal polyuria is not a specific finding of left-sided heart failure, but it may occur in clients who have renal impairment, diabetes mellitus, or diuretic therapy.
d. Jugular distention is another sign of right-sided heart failure, due to the increased central venous pressure and backward flow of blood into the superior vena cava. It is visible as a bulging of the neck veins, especially when the client is in a semi-Fowler's position.
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