The nurse is caring for a patient with venous stasis ulcers. What actions should the nurse take?
Instruct the patient to wear constrictive clothing.
Encourage the patient to keep legs in a dependent position.
Encourage frequent ambulation.
Apply compression stockings.
The Correct Answer is D
Choice A reason: Instructing the patient to wear constrictive clothing is incorrect, as it can worsen venous stasis ulcers by impeding blood flow.
Choice B reason: Encouraging the patient to keep legs in a dependent position is not recommended, as elevation helps in reducing venous pressure.
Choice C reason: Frequent ambulation is encouraged to promote blood circulation and prevent stasis.
Choice D reason: Applying compression stockings is a standard care practice to help reduce venous pressure and prevent fluid from pooling in the legs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Ensuring the patient has no questions before signing the consent is a standard and appropriate practice.
Choice B reason: A nurse can witness the patient's signature on the consent form, which is a normal procedure.
Choice C reason: Consent is not universally good for 30 days; it is specific to the procedure and timing, and this statement could mislead and cause legal issues.
Choice D reason: Saying that informed consent protects the hospital from all lawsuits is incorrect and could lead to a false sense of security, as informed consent is about patient autonomy, not just legal protection.
Correct Answer is A
Explanation
Choice A reason: Emptying the drain device every shift is important to prevent infection and accumulation of fluid, which can impede healing.
Choice B reason: Minimizing use of the affected arm is not recommended; rather, gentle exercises to promote circulation and prevent lymphedema are usually encouraged.
Choice C reason: Measuring the circumference of both arms can be part of monitoring for lymphedema, but it is not the priority in immediate post-mastectomy care.
Choice D reason: Placing the affected arm below the level of the heart is not recommended as it can increase swelling; elevation is usually advised.
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