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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Decreasing the flow rate of the irrigation solution is not the best action in this situation. The presence of blood clots in the tubing and collection bag indicates that the client may be experiencing clot retention, which can lead to urinary obstruction. Decreasing the flow rate may not provide sufficient force to dislodge clots from the catheter, which could exacerbate the problem.
Choice B rationale
Manually irrigating the catheter is the most appropriate action when blood clots are observed in the tubing and collection bag. Clots can obstruct the catheter and disrupt the continuous bladder irrigation, leading to urinary retention and increased discomfort for the client. Manual irrigation can help dislodge and remove these clots, ensuring the patency of the catheter and the effectiveness of the irrigation.
Choice C rationale
Discontinuing the infusion of the irrigation solution is not the best action in this situation. The purpose of continuous bladder irrigation after a transurethral resection of the prostate is to prevent clot formation and retention by continuously flushing the bladder. Discontinuing the infusion could lead to the formation of more clots, potentially causing urinary obstruction.
Choice D rationale
While monitoring catheter drainage is an important part of postoperative care, it is not the most appropriate action in this situation. The presence of blood clots in the tubing and collection bag indicates a potential problem that requires immediate intervention. Simply monitoring the situation without taking action to resolve it could lead to urinary obstruction and increased discomfort for the client.
Correct Answer is D
Explanation
Choice A rationale
Antibiotics are typically used to treat bacterial infections, not fungal infections like athlete’s foot. Therefore, using antibiotics would not be effective in this case.
Choice B rationale
While it’s important to use treatments for the full recommended duration to ensure the infection is completely eradicated, using an antibiotic ointment for a fungal infection like athlete’s foot would not be effective.
Choice C rationale
While it’s true that applying too much ointment can deter its effectiveness, the main issue here is that an antibiotic ointment is not the correct treatment for a fungal infection like athlete’s foot.
Choice D rationale
Athlete’s foot is a fungal infection that thrives in warm, moist environments. Therefore, keeping the feet dry and clean is an important part of managing and preventing athlete’s foot. This includes wearing clean socks and allowing the feet to dry completely before putting on shoes.
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