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 C
Explanation
A. Tachypnea: Tachypnea (rapid breathing) is not a typical effect of magnesium sulfate. Magnesium sulfate is more likely to cause respiratory depression, especially at higher doses, rather than increasing the rate of breathing.
B. Tachycardia: Tachycardia (rapid heart rate). is not a common finding with magnesium sulfate administration. Magnesium sulfate typically causes a decrease in heart rate (bradycardia. and may also contribute to hypotension.
C. Hypotension: Hypotension is the correct finding. Magnesium sulfate has a vasodilatory effect, which can lead to a drop in blood pressure. This is a well-known side effect of magnesium sulfate, particularly when administered intravenously.
D. Hyperthermia: Hyperthermia (elevated body temperature). is not a typical finding associated with magnesium sulfate. Instead, magnesium sulfate can sometimes cause mild flushing, but it does not generally lead to an increase in body temperature.
Correct Answer is A
Explanation
A. Chadwick's sign is correct. Chadwick's sign refers to a purplish or bluish discoloration of the vagina and vulva that occurs early in pregnancy due to increased blood flow to the pelvic area. This is typically seen around the 8th week of gestation.
B. Hegar's sign is incorrect. Hegar's sign refers to the softening of the lower uterine segment, which is a physical change that can be felt during a pelvic examination. It is a sign of pregnancy but does not involve discoloration of the vaginal area.
C. Chloasma is incorrect. Chloasma, also called the "mask of pregnancy," refers to hyperpigmentation on the face, typically over the cheeks and forehead, not the vagina or vulva.
D. Ballottement is incorrect. Ballottement refers to a physical finding during a pelvic exam in which the examiner can feel the fetus floating in the amniotic fluid, typically observed after 16 weeks of pregnancy. It is unrelated to changes in vaginal or vulvar color.
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