If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid?
a. Putting the patient in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots.
b. Having the patient flex, extend, and rotate her feet, ankles, and legs.
c. Having the patient sit in a chair.
d. Notifying the physician immediately if a positive Homans' sign occurs.
ANS: C
Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear may. TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. A positive Homans' sign (calf muscle pain or warmth, redness, or tenderness) requires the physician's immediate attention.
You might also like to view...
A 68-year-old patient tells the nurse that she can't smell as well as before, feels like her nose is drier, and occasionally gets a nosebleed. The nurse explains that:
1. she may have an infection. 2. she has normal age-related changes. 3. she may have a nasal defect. 4. her allergies are causing her symptoms and she should use an over-the-counter decongestant.
A nurse is caring for a client with newly diagnosed hypertension. What dietary teaching should be included in the plan of care for this client?
A. "Avoid the use of canned or processed foods." B. "There is no dietary restriction on alcohol intake." C. "You may use salt substitutes freely for flavoring." D. "You may cook with salt, but do not add additional salt when your food is served."
The primary purpose of licensure for RNs is to:
a. prevent others from using the title nurse. b. demonstrate a specialized body of knowledge. c. protect the public. d. enhance recognition for the profession.
The nurse is assessing the integumentary status of a patient diagnosed with chronic renal failure. Which of the following will the nurse most likely assess in this patient?
1. skin damp and mottled in color 2. skin pale with good turgor 3. skin flushed with poor turgor 4. skin dry, yellow-brown in color, with pruritis