AG1 Ati Chapter Questions Session 1

* ATI RN Adult Medical Surgical Nursing  * Ch 68 and 69: DIagnostics and Therapies * Ch 71, 72: MSK Disorders * Ch 73: OA only (Low-Back Pain will be covered later in Neuro content) * ATI RN Nutrition: * Chapter 1 * Chapter 7: pages 42-43 only * ATI Fundamentals: * Ch 14: Ergonomics Principles * Ch 40: Mobility and Immobility

1. A nurse is completing preoperative teaching for a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? (Select all that apply)

A. "Avoid damage or moisture to the cast on your arm

B. "Inspect your incision daily for indications of infection"

C "Apply ice packs to the area for the first 24 hours"

D. "Keep your arm in a dependent position"

E. "Perform isometric exercises"

B,C,E are correct. When taking action, the nurse should tell the client to inspect the mision for evidence of inferrina Madness, swelling, purulent draina note ice packs to the affected the first 24 reduce swelling and discomfort. The client should isometric exercises as prescribed by the provider the surse should identify that a cast is not typically required following arthroscopy. The client should elevate the affected extremity for 12 to 24 hours to reduce swelling

2. A nurse is planning care for a client who is postoperative following an arthroscopy of the knee. Which of the following nursing actions are appropriate? (Select all that apply.)

A. Assess color and temperature of the extremity

B. Apply warm compresses to incision sites.

C. Place pillows under the extremity

D. Administer analgesic medication

E. Assess pulse and sensation in the foot

A,C,D,E CORRECT: When generating solutions the nurse should plan to assess color and temperature of the affecte extremity to help identify alterations in om planning care, the nurse should identify that elevating the leg in circulation. When will help decrease swelling and pain in the affected extremitu Administering analgesic medication helps relieve joint pain in the affected extremity Assessing the pulse and sensat affected extremity helps identify alterations in circulation. The nurse should plan to apply cold compresses on the incisional site for the first 24 hours to help decrease swelling and pain NCLEX Connection: Physiological Adaptation, Alterations in Body Systems

3. A nurse is teaching a client who is going to have a bone scan. Which of the following statements should the nurse include?

A "You will receive an injection of a radioactive isotope when the scanning procedure begins"

B. "You will be inside a tube-like structure during the procedure."

C. "You will need to take radioactive precautions with your urine for 24 hours after the procedure."

D. "You will have to urinate just before the procedure."

D. CORRECT: The nurse should inform the client that they will need to urinate prior to the procedure. An empty bladder promotes visualization of the pelvic bones. The client should be informed that the radioactive isotope is injected intravenously (V) 2 to 3 hours before the scanning. Inform the client that the procedure does not use a tube-like structure as for an MR. The client should be told that radioactive precautions for their urine are not necessary following the procedure.

4. A nurse is educating clients at a health fair about dual-energy x-ray absorptiometry (DEXA) scans Which of the following information should the nurse include? (Select all that apply)

A. The test requires the use of contrast material

B. The hip and spine are the usual areas the device scans.

C. The scan detects osteoarthritis

D. Bone pain can indicate a need for a scan.

E. Females aged 40-49 years should have a baseline scan

B. D. E. CORRECT: When taking action, the nurse should inform the client that the most common areas for a DEXA scan are the hip and spine for more clear visualization of a large area of bone. The nurse should tell the client that bone pain, loss of height, and fractures are findings that can indicate the need for a DEXA scan. Inform the client that a that a baseline stan for females in their 40s is helpful for comparison with a scan during the postmenopausal period. When teaching the client, tell them that a DEXA scan detects osteoporosis, not osteoarthritis and that a DEXA scan does not require contrast material

5. A nurse is planning care for a client who will undergo an electromyography (EMG). Which of the following actions should the nurse include? (Select all that apply)

A. Assess for bruising

B Administer aspirin prior to the procedure.

C. Determine whether the client takes a muscle relaxant

D. Instruct the client to flex muscles during needle insertion.

E. Expect swelling, redness, and tenderness at the insertion sites.

A.C.D CORRECT: When generating solutions, the nurse should identify that some bruising can occur at the needle insertion sites. The nurse should assess the client's medications to determine if they take a muscle relaxant, which can decrease the accuracy of the test results. The nurse should ask the client to flex their muscles for an easier insertion of the needle into the muscle. The client should withhold arce anticoagulant medication prior to the procedure to reduce the risk of bleeding. The nurse should instruct the client to report swelling, redness, and tenderness at the insertion sites to the provider because this can indicate an infection

A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. (Select all that apply) The nurse should expect which of the following findings:

A. Skin reddened over the joint

B. Pain when bearing weight

C. Joint crepitus

D. Swelling of the affected joint

E. Limited joint motion

B,C,D,E. CORRECT: The nurse should recognize the cues from the client's assessment and determine pain when and limited joint motion are expected findings for a client bearing weight, joint crepitus, swelling of the affected joint, that requires arthroplasty of the affected joint.

A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure?

A. Age 55 years

B. History of cancer

C. Previous joint replacement

D. Bronchitis 2 weeks ago

D. CORRECT: The nurse should analyze the cues from the client's health record and determine that a recent infection such as bronchitis can cause failure of the prosthesis if the microorganisms are still present in the body and migrate to the surgical site.

A nurse working on an orthopedic unit is caring for a client following a total knee replacement. Which of the following actions should the nurse take? (Select all that apply.)

A. Check continuous passive motion device settings.

B. Palpate dorsal pedal pulses.

C. Place a pillow behind the knee.

D. Request a referral for outpatient physical therapy

E. Apply heat therapy to incision.

A, B, D, CORRECT: When taking actions, the nurse should check the continuous passive motion settings to ensure the settings are as prescribed. The nurse should monitor the strength of the pedal pulses of both lower extremities to determine adequate circulation. The nurse should also request a referral for outpatient physical therapy to continue exercises of range of motion of the operated joint.

nurse is providing postoperative care for a client following a total hip arthroplasty. Which of the following should the nurse review with the client? (Select all that apply.)

A. Provide a raised toilet seat for the client

B. Place client in a low reclining chair.

C. Instruct the client to roll onto the operative hip

D. Use an abductor pillow when turning the client

E. Instruct the client on the use of an incentive spirometer

A, D, E. CORRECT: When taking actions, the nurse should provide a raised toilet seat for the client to avoid hip flexion of 90 degrees which cause dislocation of the operated hip. The nurse should place an abductor pillow in between the client's legs when turning to prevent dislocation of the operated hip. The nurse should also instruct the client to perform incentive spirometry exercises to promote alveolar expansion and avoid postoperative respiratory complications.

A nurse is providing teaching for a client who had a total hip arthroplasty. Which of the following information should the nurse include? (Select all that apply.)

A. Clean the incision daily with soap and water

B. Turn toes inward when sitting or lying

C. Remain at a 90 degree angle when sitting

D. Bend at the waist when putting on socks

E. Use a raised toilet seat

A, C, E, CORRECT: When taking actions, the nurse should instruct the client to clean the incision daily with soap and water to prevent an infection. The client should remain no more than 90 degree angle flexion when sitting and externally rotate the toes to avoid dislocation of the hip. The client should use a raised toilet seat to prevent extreme flexion of the hip which can cause dislocation.

A nurse is providing dietary teaching about calcium-rich foods with a client who has osteoporosis. Which of the following foods should the nurse include in the instructions?

A. White bread

B. Broccoli

C. Apples

D. Brown rice

A. Food choices such as white bread, apples, and brown rice may have some calcium; however, the content of calcium is not very high.

B. CORRECT: When taking action to provide dietary teaching for a client who has osteoporosis, the nurse should include food choices that are high in calcium such as dairy products and green leafy vegetables (broccoli, kale, mustard greens).

C. Food choices such as white bread, apples, and brown rice may have some calcium; however, the content of calcium is not very high.

D. Food choices such as white bread, apples, and brown rice may have some calcium; however, the content of calcium is not very high.

A nurse is performing health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis? (Select all that apply.)

A. A 40-year-old client who has been taking prednisone for 1 month

B. A 30-year-old client who jogs 12 mile daily

C. A 45-year-old client who has been taking phenytoin for 20 years

D. A 65-year-old client who has been taking furosemide for 15 years

E. A 50-year-old client who has smoked tobacco for 5 years

C, D, E. CORRECT: While performing health screenings the nurse recognizes risk for osteoporosis include chronic use of certain medications such as anticonvulsants or loop diuretics, age greater than 50, tobacco smoke. Therefore, the clients who are at risk for developing osteoporosis include the 45-year-old client who has been taking phenytoin for 20 years, 65-year- old client who has been taking furosemide for 15 years, and 50-year-old client who has smoked tobacco for 5 years.

A nurse is reviewing the electronic health record (EHR) of a client who has suspected osteoporosis. Which of following findings should the nurse identify as a risk factor for osteoporosis? (Select all that apply.)

A. History of consuming 3 alcoholic beverages daily

B. Loss in height of 2 in (5.1 cm)

C. Body mass index (BMI) of 28

D. History of hyperthyroidism

E. Age less than 45

A, B, D. CORRECT: When recognizing cues, the nurse should identify after reviewing the client's EHR, that consuming 3 or more alcoholic beverages daily, loss in height of 2 in (5.1 cm) and a history of hyperthyroidism are risk factors for osteoporosis. Other risk factors include age greater than 50.

A nurse is planning discharge teaching on home safety for a client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A. Remove throw rugs in walkways.

B. Use prescribed assistive devices.

C. Remove clutter from the environment.

D. Wear soft-bottomed shoes

E. Maintain lighting of doorway areas.

A, B, C, E. CORRECT: The nurse should plan to include information to promote a safe environment and prevent falls such as: removing throw rugs in walkways, using prescribed assistive devices, removing clutter, wearing rubber-bottomed shoes, and maintaining good lighting in doorway areas.

A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following actions should the nurse take?

A. Apply heat to the puncture site.

B. Place the client in a supine position.

C. Turn the client every 1 hr.

D. Ambulate the client within the first hour of the procedure

A. Applying heat, turning every 1 hour, and ambulating within the first hour are contraindicated because the client should remain in a supine position for at least an hour.

B. CORRECT: When taking action while caring for a client following vertebroplasty, the nurse should ensure the client maintains a supine position for at least 1 hour to prevent injury.

C. Applying heat, turning every 1 hour, and ambulating within the first hour are contraindicated because the client should remain in a supine position for at least an hour.

D. Applying heat, turning every 1 hour, and ambulating within the first hour are contraindicated because the client should remain in a supine position for at least an hour.

A nurse is teaching a class about types of tractions. Sort the following characteristics into those associated with skin traction and those associated with skeletal traction.

A. Screws are inserted into bone

B. Uses 15 to 30 lb weights

C. Weights are attached to a boot

D. Uses 5 to 10 lb weights

SKIN TRACTION: C, D, SKELETAL TRACTION: A, B

When taking actions, the nurse should instruct that light weights are attached to a boot with skin traction to reduce muscle spasms in hip and proximal femur fractures. Screws are inserted into the bone and heavy weights are used with skeletal traction to provide longer traction time

1. A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (Select all that apply.)

A. Heberden's nodes

B. Swelling of all joints

C. Small body frame

D. Enlarged joint size

E. Limp when walking

1. A. CORRECT: The nurse should recognize the cues from the client's assessment and expect Heberden's nodes which are enlarged nodules on the distal interphalangeal joints of the hand and feet of a client who has osteoarthritis.

D. CORRECT: The nurse should expect the client's joints to be enlarged due to bone hypertrophy.

E. CORRECT: The nurse should also expect the client to limp when walking due to pain from inflammation of the localized joint who has osteoarthritis.

2. A nurse is teaching a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include? (Select all that apply.)

A. Apply heat to joints to alleviate pain

B. Ice inflamed joints for 30 min after activity

C. Reduce the amount of exercise done on days with increased pain

D. Prop the knees with a pillow while in bed

E. Wear foot insoles in shoes

A. CORRECT: When taking actions, the nurse should instruct the client to apply heat to their joints which can provide temporary relief of pain

B. The nurse should instruct the client to apply heat to their joints, which can provide temporary relief of pain.

C. CORRECT: The nurse should instruct the client to reduce the amount of exercise done on days of increased pain to prevent harm to their joints.

D. The nurse should instruct the client to avoid placing pillows behind their knees while in bed to help prevent joint damage.

E. CORRECT: The nurse should also instruct the client to wear foot insole in their shoes to relieve pressure of their joints

3. A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include?

A. Continuous pain relief is provided

B. Put on gloves before applying the cream to other parts of the body

C. Remove cream is burning sensation occurs

D. Apply the medication every 2 hr during the day

A. Capsaicin cream does not provide continuous pain relief.

B. CORRECT: When taking actions, the nurse should instruct the client to put on gloves before applying cream to parts of the body other than the hands.

C. Capsaicin can cause a burning sensation.

D. Capsaicin cream can be applied topically 3-4 times daily, not every 2 hours.

4. A nurse is caring for a client who injured their lower back due to a fall and reports sharp pain in their back and down their left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease the pain?

A. Prone without use of pillows

B. Semi-Fowler's with a pillow under the knees

C. High-Fowler's with the knees flat on the bed

D. Supine with the head flat

B. CORRECT: When taking actions, the nurse should place the client in semi-Fowler's position with the knees flexed by pillows. This relieves low back pain caused by a building disk and nerve root involvement.

5. A nurse is teaching a client who has a history of low-back injury. Which of the following instructions should the nurse provide the client to prevent future problems with low back pain? (Select all that apply.)

A. Engage in regular exercise including walking

B. Sit for up to 10 hr each day to rest the back

C. Maintain weight within 25% of ideal body weight.

D. Create a smoking cessation plan

E. Wear low-heeled shoes

A. CORRECT: When taking actions, the nurse should instruct the client to engage in regular exercise including walking or swimming which prevent low-back pain.

B. The nurse should instruct the client to engage in regular exercise, including walking or swimming to prevent low back pain.

C. The nurse should instruct the client to maintain an optimal body weight.

D. CORRECT: The nurse should instruct the client in stopping or limiting the amount of smoking which can decrease problems with low-back pain, as smoking can cause disk degeneration as a result of poor oxygenation.

E. CORRECT: The nurse should also instruct the client to wear low-heeled shoes. Wearing low-heeled, well-fitting shoes can prevent low-back pain. The client should avoid high-heeled shoes which cause stress on the back.

A nurse is discussing health problems associated with nutrient deficiencies with a group of clients. Which of the following conditions is associated with a deficiency of vitamin C? (Select all that apply.)

A. Dysrhythmias

B. Scurvy

C. Pernicious anemia

D. Megaloblastic anemia

E. Bleeding gums

B, E. CORRECT: When taking actions, the nurse should inform the clients that scurvy and bleeding gums are health conditions associated with a vitamin C deficiency.

A nurse is conducting a nutritional class on minerals and electrolytes. The nurse should include which of the following foods as a major source of magnesium?

A. Tuna

B. Tomatoes

C. Eggs

D. Oranges

A. CORRECT: When taking actions, the nurse should include the information that tuna and halibut are major sources of magnesium.

A nurse is reviewing information about dietary intake of iron with a client who has anemia. Which of the following is a non-heme source of iron?

A. Ground beef

B. Dried beans

C. Salmon

D. Turkey

B. CORRECT: When taking actions, the nurse should review with the client that dried beans provide non-heme iron, as do other legumes, vegetables, and grains.

A nurse is reviewing dietary recommendations with a group of clients at a health fair. Which of the following information should the nurse include?

A. "Fats should be 5% to 15% of daily calorie intake."

B. "Make protein 10% to 35% of total calories each day."

C. "Consume 1,500 mL of water from liquids and solids daily."

D. "The body needs 40 mg of iron each day."

B. CORRECT: When taking actions, the nurse should include in their review that the dietary recommendation for protein intake is 10% to 35% of total daily calories.

A nurse is teaching a group of clients who are pregnant about iron-rich foods. Which of the following foods should the nurse include? (Select all that apply.)

A. Beans

B. Fish

C. Dairy products

D. Lean red meats

E. Apples

A, B, D. CORRECT: When taking actions, the nurse should instruct the clients who are pregnant about iron-rich foods which include beans, fish, and lean red meats. Dairy products and apples are not foods rich in iron.

A nurse is educating the parents of a toddler about appropriate snack foods. Which of the following foods should the nurse include? (Select all that apply.)

A. Graham crackers

B. Apple slices

C. Raisins

D. Jelly beans

E. Cheese cubes

A, B, E. CORRECT: When taking actions, the nurse should instruct the parents of a toddler that graham crackers, apple slices, and cheese cubes are appropriate snacks. Raisins because they pose a choking risk and are difficult to chew.

A nurse is assessing a 6-month-old infant who has a lactose intolerance. Which of the following findings should the nurse expect? (Select all that apply.)

A. Abdominal distention

B. Flatus

C. Hypoactive bowel sounds

D. Occasional diarrhea

E. Visible peristalsis

A, B, D. CORRECT: When recognizing cues, the nurse should expect an infant who is lactose intolerant to have abdominal distention, flatus, and occasional diarrhea. Hypoactive bowel sounds and visible peristalsis are not associated with lactose intolerance.

A school nurse is teaching a group of adolescents about healthy snack food choices. Which of the following foods should the nurse include? (Select all that apply.)

A. Carrot sticks with low-fat dip

B. Cheese and crackers

C. Unbuttered popcorn

D. French fries

E. Hot dog

A, B, C. CORRECT: When taking actions, the school nurse should discuss healthy snack food choices with a group of adolescents, including carrot sticks with low- fat ranch dip, cheese and crackers, and unbuttered popcorn. French fries and hot dogs are not healthy food choices because they are high in fat and sodium

A nurse at a community center is providing nutrition counseling for a group of older adult clients. Which of the following information should the nurse include? (Select all that apply.)

A. Increase protein to 50% of daily calories.

B. The need for vitamins and minerals can increase.

C. Up to 35% of daily calories should come from fat.

D. At least 45% of daily calories should come from carbohydrates.

E. Fruits and vegetables should make up one-third of each meal.

B, C, D. CORRECT: When taking actions, the nurse should include the following information in nutritional education for a group of older adult clients: Age-related changes can reduce the body's ability to absorb vitamins and minerals. Adult clients should obtain 20% to 35% of daily calories from fat. Adult clients should obtain 45% to 65% of daily calories from carbohydrates. Fruits and vegetables should make up one-half of each meal. Also, protein requirement do not increase during older adulthood.

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.)

A. "My line of gravity should fall outside my base of support."

B. "The lower my center of gravity, the more stability I have."

C. "To broaden my base of support, I should spread my feet apart."

D. "When I lift an object, I should hold it as close to my body as possible."

E. "When pulling an object, I should move my front foot forward."

A. To reduce the risk of falling, the line of gravity should fall within the base of support, not outside it.

B. CORRECT: The new employee should identify that being closer to the ground lowers the center of gravity, which leads to greater stability and balance.

C. CORRECT: Spreading the feet apart increases and widens the base of support.

D. CORRECT: Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevents injury and instability.

E. To promote stability, move the rear leg back when pulling on an object.

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time?

A. Obtain a walker for the client to use to transfer back to bed.

B. Call for additional staff to assist with the transfer.

C. Use a transfer belt and assist the client back into bed.

D. Determine the client's ability to help with the transfer.

A. Although this might be a necessary assistive device for this client, obtaining a walker is not the priority action the nurse should take.

B. Although this might be necessary for a safe transfer, calling for assistance is the not the priority action the nurse should take.

C. Although this might be a necessary assistive device for the transfer of this client, using a transfer belt is not the priority action the nurse should take.

D. CORRECT: The first action that should be taken using the nursing process is to assess or collect data from the client. Determine the client's ability to help with transfers and then proceed with a safe transfer.

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.)

A. Request assistance when repositioning a client.

B. Avoid twisting your spine or bending at the waist.

C. Keep your knees slightly lower than your hips when sitting for long periods of time.

D. Use smooth movements when lifting and moving clients.

E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles

A. CORRECT: The nurse should identify that to reduce the risk of injury, at least two staff members should reposition clients.

B. CORRECT: Twisting the spine or bending at the waist (flexion) increases the risk for injury.

C. When sitting for long periods of time, it is essential to keep the knees slightly higher, not lower, than the hips to decrease strain on the lower back.

D. CORRECT: Using smooth movements instead of sudden or jerky muscle movements helps prevent injury.

E. It is important to take a break every 15 to 20 min, not every 2 to 3 hr, from repetitive movements to flex and stretch joints and muscles.

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client?

A. Supine

B. Semi-Fowler's

C. Lateral Semi-prone Recumbent

D. Trendelenburg

A. In the supine position, the client lies on their back with the head and shoulders elevated on a pillow. This angle will not prevent regurgitation.

B. CORRECT: In the semi-Fowler's position, the client lies supine with the head of the bed elevated 15° to 45° (typically 30°). This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. This is the safest position for clients receiving enteral tube feedings.

C. In the lateral semi-prone recumbent position, the client is on their side halfway between lateral and prone positions. This position is not safe because it promotes regurgitation.

D. In the Trendelenburg position, the entire bed is tilted with the head of the bed lower than the foot of the bed. This position is not safe because it promotes regurgitation.

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make?

A. "Lie on your back with your head and shoulders supported by a pillow."

B. "Have your head turned to the side while you lie on your stomach."

C. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table."

D. "Lie on your side with your top arm resting on the bed and your weight on your hip."

. Instructing the client to lie on their back with their head and shoulders supported by a pillow is describing the supine position, not the orthopneic position.

B. Instructing the client to lie on their stomach with their head turned to the side is describing the prone position, not the orthopneic position.

C. CORRECT: The nurse should instruct the client to have a table beside the bed so they can sit on the bedside and rest their arms on the table. This is an accurate description for the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD.

D. Instructing the client to lie on their side with their top arm resting on the bed and their weight on their hip is describing the lateral or side-lying position, not the orthopneic position.

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client?

A. Decreased subcutaneous fat

B. Muscle atrophy

C. Pressure injury

D. Fecal impaction

A. The client is at risk for decreased subcutaneous fat due to altered mobility. However, there is another risk that is the priority.

B. The client is at risk for muscle atrophy due to altered mobility However, there is another risk that is the priority.

C. CORRECT: When prioritizing hypotheses, the nurse should identify that the greatest risk to this client is Injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift their weight every 15 min, and reposition the client after 1 hr

D. The client is at risk for fecal impaction due to altered mobility. However, there is another risk that is the priority.

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.)

A. Instruct the client not to perform the Valsalva maneuver.

B. Apply elastic stockings.

C. Review laboratory values for total protein level.

D. Place pillows under the client's knees and lower extremities.

E. Assist the client to change positions often.

A. The Valsalva maneuver increases the workload of the heart, but it does not affect peripheral circulation.

B. CORRECT: When taking actions, the nurse should identify that elastic stockings promote venous return and prevent thrombus formation.

C. A review of the client's total protein level is important for evaluating his ability to heal and prevent skin breakdown.

D. Placing pillows under the knees and lower extremities can impair circulation of the lower extremities.

E. CORRECT: When taking actions, the nurse should identify that frequent position changes prevent venous stasis

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.)

A. Hold the cane on the right side.

B. Keep two points of support on the floor.

C. Place the cane 38 cm (15 in) in front of the feet before advancing.

D. After advancing the cane, move the weaker leg forward.

E. Advance the stronger leg so that it aligns evenly with the cane.

A. CORRECT: When taking actions, the nurse should instruct the client to hold the cane on the uninjured side to provide support for the injured left leg.

B. CORRECT: When taking actions, the nurse should instruct the client to keep two points of support on the ground at all times for stability.

C. The client should place the cane 15 to 25 cm (6 to 10 in) in front of their feet before advancing.

D. CORRECT: When taking actions, the nurse should instruct the client to advance the weaker leg first, followed by the stronger leg.

E. The client should advance the stronger leg past the cane.

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?

A. Encourage the client to perform antiembolic exercises every 2 hr.

B. Instruct the client to cough and deep breathe every 4 hr.

C. Restrict the client's fluid intake.

D. Reposition the client every 4 hr

A. CORRECT: When generating solutions, the nurse should encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation.

B. The nurse should instruct the client to cough and deep breathe every 1 to 2 hr to reduce the risk of atelectasis.

C. The nurse should increase the client's intake of fluids, unless contraindicated, to reduce the risk of thrombus formation, constipation, and urinary dysfunction.

D. The nurse should plan to reposition the client every 1 to 2 hr to reduce the risk for pressure injuries.