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

Answer and Explanation

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

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Correct Answer is A

Explanation

A. Telling the APs to stop the conversation is correct. Discussing client information in a public area violates HIPAA (Health Insurance Portability and Accountability Act) privacy regulations. The nurse should immediately intervene and remind the APs about maintaining client confidentiality.

B. Documenting the event in the client's progress notes is incorrect. Client progress notes should contain only information relevant to client care. Documenting an overheard conversation about a privacy violation does not belong in the medical record.

C. Informing the client of the APs' actions is incorrect. While privacy is essential, informing the client may cause unnecessary distress. The nurse should focus on correcting the behavior of the APs rather than alarming the client.

D. Submitting an incident report to the risk manager is incorrect. While some breaches of confidentiality require reporting, the first step is to address the issue directly with the APs. If the behavior continues or is severe, reporting to a supervisor may be necessary.

A. A client who has a sodium level of 140 mEq/L after one episode of diarrhea. B. A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf. C. A client who has atrial fibrillation and an INR of 4. D. A client who reports chest pain after ambulating.

Correct Answer is A

Explanation

A. "A client who has a sodium level of 140 mEq/L after one episode of diarrhea." This is the correct choice. A sodium level of 140 mEq/L is within the normal range, and the client has had only one episode of diarrhea, suggesting that they are stable and could be safely discharged.

B. "A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf." This is a concern. The warm, red area on the calf could indicate the presence of a deep vein thrombosis (DVT) or infection, both of which require further evaluation and management.

C. "A client who has atrial fibrillation and an INR of 4." This is concerning. An INR of 4 indicates an increased risk of bleeding, which requires closer monitoring and potentially adjusting the anticoagulation therapy before discharge.

D. "A client who reports chest pain after ambulating." This is an urgent issue that needs immediate attention. Chest pain could indicate a serious cardiac event, such as a myocardial infarction, and the client should not be discharged until further evaluation is performed.

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