The nurse caring for the postpartum client who has developed thrombophlebitis is providing instructions in the management of this condition. Which client statement indicates the need for further instruction?
“I will wear my elastic stockings as prescribed.”.
“I will massage my affected leg regularly.”.
“I will avoid prolonged sitting.”.
“I will elevate my leg if it is swollen.”.
“I will elevate my leg if it is swollen.”.
The Correct Answer is B
Choice A rationale
Elastic stockings help improve venous return, reducing clot propagation in thrombophlebitis. Proper usage minimizes symptoms like pain and swelling, and supports overall vein health, crucial for recovery and preventing complications.
Choice B rationale
Massaging an affected leg with thrombophlebitis is contraindicated as it increases the risk of clot dislodgement, potentially leading to a life-threatening pulmonary embolism. This misconception highlights the need for further client education.
Choice C rationale
Avoiding prolonged sitting prevents venous stasis and encourages circulation, which is vital in thrombophlebitis management to prevent worsening of clotting and associated complications such as pain or swelling.
Choice D rationale
Elevating the affected leg reduces swelling and promotes venous drainage, alleviating discomfort associated with thrombophlebitis. This intervention supports the resolution of inflammation in the superficial veins.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A pulse rate of 80 and regular does not directly indicate Methergine's effectiveness. Normal pulse ranges from 60 to 100 beats per minute. This could result from overall stabilization rather than medication effect.
Choice B rationale
A firm uterine fundus at the umbilicus and moderate lochia indicate effective uterine contraction and hemostasis, reflecting successful intervention with Methergine in managing postpartum hemorrhage.
Choice C rationale
A blood pressure of 120/80 is within the normal adult range but does not specifically reflect Methergine's uterotonic action. Blood pressure monitoring is essential but not the primary efficacy indicator.
Choice D rationale
An increase in prothrombin time reflects coagulation changes but is unrelated to Methergine's mechanism of action. It focuses on hemostatic effects via uterine contractions rather than coagulation pathways.
Correct Answer is D
Explanation
Choice A rationale
Engorgement is caused by milk overproduction or improper drainage rather than cracked nipples. While related to breastfeeding issues, it is not directly linked to cracked or bleeding nipples.
Choice B rationale
Mastitis is an infection of breast tissue that occurs due to milk stasis or blocked ducts. Cracked nipples increase infection risks, but mastitis is secondary to these infections.
Choice C rationale
Decrease in milk production is influenced by hormonal imbalances or poor latch rather than by cracked or bleeding nipples. It does not directly result from nipple trauma.
Choice D rationale
Cracked nipples create an entry point for bacteria, significantly increasing infection risks such as cellulitis or abscess formation. Proper hygiene and wound care are essential to reduce complications.
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