The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

Eat a diet that is high in protein and vitamins A and C.

Maintain bed rest as much as possible.

Keep legs elevated when sitting or lying down.

Inspect ankles daily for areas of darkening skin.

Apply intermittent cold compresses four times daily.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale
Eating a diet that is high in protein and vitamins A and C is beneficial for wound healing. Protein is essential for tissue repair, while vitamins A and C play a crucial role in collagen synthesis, which is vital for wound healing.
Choice B rationale
Maintaining bed rest as much as possible is not the best advice for a patient with venous leg ulcers. Mobility improves blood circulation, which can aid in the healing of the ulcers.
Choice C rationale
Keeping legs elevated when sitting or lying down can help reduce swelling and improve blood flow, which can promote healing of the ulcers.
Choice D rationale
Inspecting ankles daily for areas of darkening skin is important as it can help in early detection of any potential complications or worsening of the condition.
Choice E rationale
Applying intermittent cold compresses four times daily is not typically recommended for venous leg ulcers. The standard treatment involves cleaning and dressing the wound, using compression therapy, and in some cases, taking prescribed medications.

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Correct Answer is A

Explanation

Choice A rationale
An ABO incompatibility reaction can occur if a patient receives the wrong type of blood during a blood transfusion. Symptoms of an ABO incompatibility reaction include lower back pain and hypotension, which are serious and should be reported immediately to the healthcare provider.
Choice B rationale
A delayed painful rash with urticaria is not typically a symptom of an ABO incompatibility reaction. While it could indicate an allergic reaction, it is not as immediate or potentially life-threatening as the symptoms in Choice A1.
Choice C rationale
Acute rhinitis and nasal stuffiness are more commonly associated with respiratory infections, not ABO incompatibility reactions. These symptoms are not typically a direct result of a blood transfusion.
Choice D rationale
Arthritic joint changes and chronic pain are not associated with ABO incompatibility reactions. These symptoms are more likely related to long-term conditions like arthritis.

A. Painful areas should be rubbed gently until the pain subsides. B. Wearing gloves when handling cold items guards against painful spasms. C. Return appointments will be needed for IV pain medication. D. Enrolling in a pain clinic can provide pain relief alternatives.

Correct Answer is B

Explanation

Choice A rationale
Rubbing painful areas gently until the pain subsides is not typically recommended for managing pain in Raynaud’s disease. This could potentially cause more harm than good19.
Choice B rationale
Wearing gloves when handling cold items can help guard against painful spasms in Raynaud’s disease. Cold temperatures can trigger Raynaud’s attacks, so protecting the hands from cold is a key part of managing the condition19.
Choice C rationale
The need for return appointments for IV pain medication is not typically a primary component of pain management in Raynaud’s disease. Pain in Raynaud’s disease is usually managed through lifestyle modifications and medications19.
Choice D rationale
While enrolling in a pain clinic can provide pain relief alternatives, it’s not the first line of management for pain in Raynaud’s disease. The primary management strategies include avoiding cold exposure and using medications to improve blood flow19.

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The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

Correct Answer is A

Explanation

A client who was recently diagnosed with Raynaud’s disease is concerned about pain management. Which nursing instruction should the nurse provide?

Correct Answer is B

Explanation

What information should the nurse include in the teaching plan for a patient diagnosed with gastroesophageal reflux disease (GERD)?

A client receives a prescription for 1 liter of lactated Ringer’s intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?

A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient’s laboratory values should the nurse review?

A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?