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- Jun 3, '12 by petethecanuckExactly. Please re-read the question:
Mr. Del Ray is experiencing an acute exacerbation of right sided heart failure. Which of the following independent nursing actions should the nurse implement to limit spread of Mr. Del Ray's ankle edema?
1. Restricting his fluids
2. Applying elastic bandages
3. Performing range-of-motion exercises
4. Elevating his legs
- Jun 3, '12 by kheemooyOkay, well not because it said "exacerbation" doesn't mean it has pulmo distress already. just stick to the question pls. don't over analyze. and besides it says "independent nursing action" and in addition, elevation of legs is more specific to ankle edema compared to restriction of fluids.
and lastly, since the question was taken from the prep guide it means that it's the CNA's answer. CNA who are the makers of the exam. so no matter how you disagree with it, in the end it still depends on their answers. and we can do nothing about that.
anyways if you provide with factual and book based source, then i will be convinced. i still stick to my answer and i have my sources.Last edit by janfrn on Jun 3, '12
- Jun 3, '12 by Christophclap clap clap!!!
- Jun 3, '12 by ChristophI may have to agree with kheemoy because we just have to answer what is being asked. For that question, "Which of the following independent nursing actions should the nurse implement to limit spread of Mr. Del Ray's ankle edema?", Let me just justify the cues that we have. First, We have the word Independent nursing action (nurse initiative) which means autonomous actions of the nurse, and based on the nursing diagnoses and client-centered goals that we us a nurse acts on our own intiative, without instructions from other persons/disciplines(physicians). Second, How do we intervene if a patient has a ankle edema? Based on what i know, one of the intervention for ankle edema (swollen legs or ankle) is to Raise your legs above your heart while lying down.
Although #1 restricting his fluid is a good answer. We need an order from the doctor before we can implement that. So it will not be a independent nursing action. It will be Interdependent intervention.
So I therefore conclude that my answer to that question is #4 Elevating his legs
- Jun 3, '12 by allicandoisprayjust to be clear the question and answer did not come from the CNA, it was in mosby's. the question was just a poor question overall. throughout my readings i was under the impression elevation of legs to relieve edema is completely contraindicated in patient's with CHF so this question is off base in my humble opinion.
- Jun 3, '12 by kheemooy@ allicandoispray --- can you provide us any readings that elevation of leg is contraindicated in CHF, mosby's doesn't say that and i searched for answer i didn't find anything that says it's contraindicated in CHF.
@ christoph --- we have the same thoughts about this question. i agree with everything you said. you definitely got my point.Last edit by janfrn on Jun 4, '12 : Reason: enabled multiple quote reply
- Jun 4, '12 by janfrnElevation of the legs is not contraindicated in CHF.
- Jun 4, '12 by jvre888so that answered the question. Thanks janfrn.
- Jun 4, '12 by allicandoispraythank you for the clarification janfrn!
kheemooy, i apologize, not contraindicated. it is just mentioned in mosby's (with Lewis reference) that elevation of extremities should be avoided in patient's with heart failure as it increases venous return, placing an increased workload on the heart.
thank you for sharing why you believe the answer was correct. i still feel that this question was strange.
- Jun 4, '12 by jvre888i never encountered any med-surg book that said elevation of leg is completely contraindicated in chf. or i just don't read med-surg book that much. lol..