The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)

Avoid prolonged standing or sitting.

Continue wearing compression stockings.

Cross legs at knee but not at ankle.

Use recliner for long periods of sitting.

Maintain the bed flat while sleeping.

Answer and Explanation

Correct Answer : A,B,D

A. Prolonged standing or sitting can worsen venous insufficiency and increase the risk of blood pooling in the legs. Encouraging the client to move around and avoid prolonged periods of immobility can help improve circulation.

B. Compression stockings help improve blood flow by applying pressure to the legs, reducing swelling and preventing blood from pooling. The client should be instructed to continue wearing them as prescribed by their healthcare provider.

C.Crossing the legs can impede blood flow and should be avoided altogether.

D. Sitting for extended periods can also contribute to blood pooling. Using a recliner allows the client to elevate their legs, promoting better circulation and reducing the risk of complications. The nurse should recommend using a recliner when sitting for long periods of time.

E. Elevating legs during sleep is generally advised to reduce venous pressure.

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Correct Answer is B

Explanation

The client is experiencing severe abdominal incisional pain, and her vital signs indicate an elevated heart rate, respiratory rate, and blood pressure. These signs suggest that the client is in distress and may be experiencing pain-related complications.

Assessing the IV site for patency is crucial to ensure that the client is receiving the prescribed IV analgesic medication effectively. If the IV site is not patent or if there is any obstruction, the administration of IV analgesics may be delayed, resulting in inadequate pain relief for the client.

While providing a pillow for splinting can offer comfort and support to the client, it is not the most critical intervention in this situation. Placing the client in a high Fowler position may help with pain management, but it is not the priority at this moment. Administering an IV analgesic is an appropriate intervention, but before doing so, it is essential to ensure that the IV site is patent.

A. Evaluate and update plans of care for clients. B. Verify the readiness of clients for discharge. C. Insert urinary catheters for uncomplicated clients. D. Receive a postoperative client and conduct the assessment.

Correct Answer is C

Explanation

Delegation involves assigning tasks to individuals who have the appropriate skills and competence to perform them safely and effectively. Inserting urinary catheters for uncomplicated clients is a task that can be delegated to a practical nurse. It is a common procedure within the scope of practice for a practical nurse, and it does not require the level of assessment and critical thinking involved in evaluating and updating plans of care or receiving a postoperative client and conducting an assessment.

Verifying the readiness of clients for discharge typically involves comprehensive assessments, coordination with other healthcare professionals, and decision-making regarding the appropriateness of discharge. This task is generally performed by registered nurses (RNs) or other members of the healthcare team with advanced training.

Evaluating and updating plans of care for clients is a responsibility that falls within the scope of practice of registered nurses. It requires a higher level of assessment, clinical judgment, and decision-making, which are typically beyond the scope of practice of a practical nurse.

Receiving a postoperative client and conducting the assessment involves comprehensive assessment skills and critical thinking, which are typically within the scope of practice of a registered nurse or an advanced practice nurse.

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The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is C

Explanation

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