INTERVENTIONS: WHAT SHOULD THE NURSE DO?

Question 1

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take?

Answer 1

1, The nurse should elevate the client’s legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart.

2. The nurse should encourage the client to ambulate 5 to 10 min every hour while awake to prevent venous stasis.
3. The nurse should discourage the client from sitting or standing for any duration to prevent venous stasis. Feet should be elevated above the heart to prevent venous stasis.
4. The nurse should instruct the client to wear graduated compression stockings for up to 1 week after surgery to promote venous return.

Question 2

ITCHING/HIVES AFTER INITIATING PACKED RBC’S

Answer 2

1. STOP THE INFUSION
2. INITIATE INFUSION NORMAL SALINE WITH NEW ADMINISTRATION SET
3. SEND THE BLOOD CONTAINER & TUBING TO THE BLOOD BANK FOR A REPEAT TYPING & CULTURE
4. OBTAIN A URINE SAMPLE FROM THE CLIENT IF HEMATURIA