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 A
Explanation
Choice A reason: Coughing and deep breathing exercises after surgery are encouraged to prevent atelectasis, which is the collapse of part or (less commonly) all of a lung.
Choice B reason: Induction is not a postoperative complication; it refers to the process of initiating anesthesia.
Choice C reason: Hypothermia is a condition of abnormally low body temperature, not directly prevented by coughing and deep breathing.
Choice D reason: Hematoma, a collection of blood outside of blood vessels, is not prevented by coughing and deep breathing exercises.
Correct Answer is D
Explanation
Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.
Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.
Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.
Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.
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