Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?

Limit intake of chips and pretzels.

Encourage mountain biking.

Elevate lower extremities.

Restrict fluid intake to water.

Answer and Explanation

The Correct Answer is C

A.   Chips and pretzels are high in sodium, which can contribute to fluid retention and exacerbate symptoms of CVI. While reducing sodium intake can help manage fluid retention and swelling, it is not the most direct action for promoting circulation itself. It’s more of an adjunctive measure that can support overall management of CVI but does not directly improve venous circulation.
B.   Mountain biking is an intense physical activity that may not be suitable for all clients with chronic venous insufficiency, especially if they have significant symptoms or mobility issues. High-impact exercises can potentially exacerbate symptoms or lead to injury. Low-impact activities are generally recommended to improve circulation and manage CVI.
C.   Elevating the lower extremities is a highly effective measure for promoting circulation in clients with chronic venous insufficiency. It helps reduce venous pressure and promotes the return of blood to the heart, thereby alleviating swelling and discomfort. This action is directly beneficial in managing CVI.
D.   Restricting fluid intake to water alone does not directly address the underlying issues of venous insufficiency. While managing overall fluid intake can be part of a comprehensive plan to prevent excessive fluid retention, it is not the most direct or effective action for promoting circulation compared to elevating the legs.

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Correct Answer is A

Explanation

A. Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B. A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C. This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D. This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.

A. Place pillows around the bed rails to provide padding. B. Watch the seizure activity and document the time and client movement. C. Manually ventilate the client with a bag-valve mask (BVM). D. Stop the IV fluids. E. Increase the supplemental oxygen to 10 L/minute via nasal cannula. F. Begin chest compressions.

Correct Answer is ["B","C","E"]

Explanation

A. This is important to prevent injury but is not the priority at this time.
B. This is important for monitoring the seizure progression and for providing information to the healthcare provider. However, it should be done while simultaneously performing the more critical interventions of ventilation and oxygenation.
C. This is the highest priority as the client is experiencing respiratory failure with a respiratory rate of 4 breaths/minute. Providing artificial ventilation is crucial to oxygenate the patient.
D. This is not necessary at this point and may not be feasible during the emergency situation.
E. While not as immediate as BVM ventilation, increasing oxygen delivery is essential to improve oxygenation levels.
F. Begin chest compressions: Chest compressions are indicated for cardiac arrest, not respiratory failure.

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Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Correct Answer is A

Explanation

Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

Correct Answer is ["B","C","E"]

Explanation

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