Examkin

Soru

Zorluk: Çok zorBasic Care and Comfort

A nurse is providing care for a client who underwent a right femoral-popliteal bypass graft 12 hours ago. The client also has a documented history of severe chronic venous insufficiency and chronic stasis dermatitis in the left lower extremity. The client is currently resting in a low-Fowler's position, reports aching discomfort in both legs, and requests an intervention for comfort. Which of the following nursing actions is most appropriate?

  1. A
    Place a supportive pillow directly under the client's knees bilaterally to relieve lower back tension and improve comfort.
  2. Maintain the right leg in a straight, un-elevated position on the mattress while elevating the left leg on a soft pillow.Cevap
  3. C
    Delegate the unlicensed assistive personnel (UAP) to perform passive range-of-motion (ROM) exercises on both legs to reduce stiffness.
  4. D
    Elevate the foot of the bed to position both of the client's lower extremities above the level of the heart.

Cevap

The most appropriate action is to maintain the right leg in a straight, un-elevated position on the mattress while elevating the left leg on a soft pillow.
The client presents with two conflicting circulatory conditions requiring highly individualized positioning. Following a femoral-popliteal bypass, the affected extremity (right leg) must be kept straight and flat (or slightly dependent) to maintain graft patency and optimize arterial blood flow. Conversely, chronic venous insufficiency in the left leg requires elevation to promote venous return and reduce edema. The correct positioning strategy synthesizes these opposing needs by keeping the right leg flat and straight, while elevating the left leg on a pillow for comfort.

Adım Adım Çözüm

1
Analyze the client's right leg positioning requirements.
The right leg has a fresh femoral-popliteal arterial bypass graft.
Arterial blood flow relies heavily on gravity and unobstructed vessels. To maintain graft patency and prevent occlusion, the right leg must be kept straight and should not be elevated above the level of the heart.
2
Analyze the client's left leg positioning requirements.
The left leg has severe chronic venous insufficiency.
Venous return is compromised in this extremity. Elevating the leg utilizes gravity to promote venous blood return to the heart, reducing edema and discomfort.
3
Evaluate the proposed interventions against the competing physiological needs.
Only positioning the right leg flat and elevating the left leg safely addresses both conditions simultaneously.
Generalized elevation harms the arterial graft, while keeping both legs dependent exacerbates venous stasis.
4
Review other basic care aspects such as delegation and safety principles.
Delegating ROM to the UAP and placing pillows directly under the knees are identified as unsafe practices.
A fresh surgical bypass graft requires continuous RN assessment, and popliteal pressure compromises all lower extremity circulation.

Anahtar Kavram

Individualized Client Positioning and Comfort Measures
Bu soruyu puanla

Konular

Basic Care and Comfort

Bu konudan daha fazla soru