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MSNCB Certified Medical-Surgical Registered Nurse - Blogs Sample Questions

Thrombophlebitis is prevented by what?

Correct Answer:
high venous flow.


thrombophlebitis is a medical condition characterized by the inflammation of a vein caused by a blood clot. it most commonly affects the leg veins and can cause pain, swelling, and redness in the affected area. preventing thrombophlebitis is crucial as it can lead to serious complications, such as pulmonary embolism, where a clot breaks loose and travels to the lungs, causing life-threatening problems.

the correct answer to preventing thrombophlebitis is maintaining high venous flow. ensuring a high venous flow helps to prevent the stagnation of blood in the veins, which is a primary risk factor for the formation of blood clots. there are several methods to maintain or increase venous flow, particularly in patients who are at risk or already experiencing symptoms of thrombophlebitis.

one effective method is the use of elastic stockings, also known as compression stockings. these stockings apply gentle pressure to the legs, promoting blood flow from the veins back to the heart. this helps in preventing blood from pooling in the veins, thereby reducing the risk of clot formation.

elevating the legs higher than the chest is another strategy to enhance venous return. this position utilizes gravity to assist the flow of blood back to the heart, diminishing the pressure in the leg veins and minimizing the likelihood of clot formation.

additionally, regular leg massages can stimulate circulation in the legs. massaging helps in mobilizing blood through the veins and can be particularly beneficial for individuals who are immobile or bedridden. providing some form of ambulation or encouraging the patient to move if possible is also essential. movement activates the muscle pump in the legs, which naturally helps push blood through the veins.

in conclusion, maintaining high venous flow is crucial in preventing thrombophlebitis. this can be achieved through methods such as wearing compression stockings, elevating the legs, massaging the legs, and encouraging mobility. these actions collectively help in promoting healthy blood circulation, thus reducing the risk of thrombophlebitis and its potential complications.

A nurse makes sure the patient understands the foods and liquids to avoid prior to being admitted for an invasive procedure. This nurse is demonstrating which nursing process?

Correct Answer:
outcome identification.


the question asks which nursing process is being demonstrated when a nurse ensures a patient understands which foods and liquids to avoid before an invasive procedure. the correct answer here is "outcome identification." to fully understand why this is the correct answer, it's helpful to review the different components of the nursing process, which include assessment, nursing diagnosis, planning, implementation, and evaluation.

assessment involves the systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community. nursing diagnosis refers to the use of critical thinking skills to identify health problems after a thorough assessment. planning involves setting measurable and achievable short- and long-range goals for patient care.

in this scenario, the nurse is focused on a specific aspect of the planning phase: outcome identification. outcome identification involves determining the specific results or desired outcomes that one aims to achieve in the care process. these outcomes guide the selection of interventions and serve as benchmarks against which to evaluate the progress of care.

the nurse in the scenario is addressing the outcome of ensuring the patient maintains proper nutrition and avoids specific foods and liquids that may interfere with the success of the upcoming invasive procedure. by informing and educating the patient about dietary restrictions, the nurse is directly contributing to achieving a successful health outcome related to the procedure.

implementation, another part of the nursing process, involves carrying out or executing the planned interventions. in this case, the nurse's action of educating the patient about what to avoid eating or drinking is an implementation of the intervention designed to achieve the identified outcome.

thus, while it may seem that the nurse is also implementing interventions (which is true), the focus on what the nurse is primarily demonstrating in this question is the process of outcome identification. she is ensuring that the goals of care (proper pre-procedure nutrition) are well understood and agreed upon, which is crucial for the success of the intervention and ultimately the procedure.