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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- While it's important for UAPs to report changes in a client's condition, the immediate priority is to assess and address the deteriorating condition of the client. The nurse's first action should be to stop the current care being provided and assess the client.
B) Correct- In this situation, the priority is to ensure the safety and well-being of the client. The client's deteriorated condition needs to be assessed promptly by a licensed nurse to determine the appropriate interventions. Stopping the care being provided by the unlicensed assistive personnel (UAP) allows the nurse to focus on the client's immediate needs.
C) Incorrect- Administering oral medications is not the immediate priority in this situation. The client's deteriorating condition takes precedence over administering medications.
D) Incorrect- While investigating the situation and addressing communication gaps is important, the first priority is to assess and address the client's current condition. The nurse needs to take immediate action to ensure the client's safety and well-being.
Correct Answer is C
Explanation
Choice A rationale: Initiating the urine collection without reporting the low serum creatinine is inappropriate. A value of 0.3 mg/dL is below the reference range and may indicate significant muscle wasting or severe malnutrition.
Choice B rationale: Evaluating the BUN level provides information about hydration and renal perfusion, but it does not address the immediate clinical significance of an abnormally low creatinine level in an older adult client.
Choice C rationale: The nurse must notify the provider because a creatinine level of 0.3 mg/dL is abnormally low. In older adults, this often reflects low muscle mass, which significantly impacts how drug dosages are calculated.
Choice D rationale: Assessing for hypokalemia is not directly indicated by a low creatinine level. While electrolyte monitoring is important in drug toxicity, it is not the priority action linked to this specific lab finding.
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