A nurse is applying antiembolic stockings for a client who is postoperative. Which of the following actions should the nurse take?
Have the client point his toes before inserting his foot into the stocking.
Remove the stockings once every 24 hr.
Elevate the client's legs for 5 min prior to applying the stockings.
Roll the top of the stocking down so it fits snugly above the client's calf
The Correct Answer is C
A. Having the client point his toes before inserting his foot into the stocking is incorrect. The nurse should instruct the client to keep the foot in a neutral position to avoid unnecessary pressure on the toes or veins.
B. Removing the stockings once every 24 hr is incorrect. Antiembolic stockings should typically be removed and reapplied at least once per shift to allow for skin assessment and hygiene. They should not remain on for 24 hours continuously.
C. Elevating the client's legs for 5 min prior to applying the stockings is correct. Elevating the legs helps promote venous return by reducing swelling in the lower extremities. This makes the application of antiembolic stockings more effective and more comfortable for the client.
D. Rolling the top of the stocking down so it fits snugly above the client's calf is incorrect. The stockings should be applied smoothly and without folds to avoid restricting circulation. The top should not be rolled down as it can create pressure points
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. "Apply the transdermal patch to either of the client's forearms" is incorrect. The nurse should avoid applying the patch to areas with excessive hair, irritation, or broken skin. Common areas include the upper torso (e.g., upper arm, chest, or back).
B. "Remove the old transdermal patch before applying a new one" is correct. To prevent overdose or accidental administration of an additional dose, the nurse should always remove the old patch before applying a new one.
C. "Apply the patch to a clean, hairless area of the client's skin" is correct. This ensures better adhesion and absorption of the medication, as hair and dirt can interfere with the patch's effectiveness.
D. "Use sterile gloves to apply and remove transdermal patches" is incorrect. Standard gloves are sufficient for applying and removing transdermal patches, as they do not need to be sterile.
E. "Dispose of old transdermal patches in a childproof container" is correct. Fentanyl patches should be disposed of properly to avoid accidental exposure or ingestion by children or pets. A childproof container ensures safe disposal.
Correct Answer is D
Explanation
A. Leaving noninvasive equipment on the client’s body is not appropriate during postmortem care. Tubing and devices should be removed unless an autopsy is required.
B. Dentures should generally be left in place to maintain the natural shape of the face and promote a more normal appearance for family viewing.
C. Turning the lights up is unnecessary and may create a harsh environment. A calm, respectful setting with normal or dim lighting is preferred during postmortem care.
D. Closing the client’s eyes before the family views the body helps provide a peaceful and dignified appearance and is an important part of postmortem care.
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