A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

A. Elevates the legs before applying the stockings: This is a correct action. Elevating the client's legs before applying elastic antiembolic stockings can help reduce swelling and improve blood flow. It's an appropriate step to prepare the client for the stockings.

B. Measures the client's calf circumference before selecting the stocking size: This is a correct action. Proper sizing of elastic antiembolic stockings is crucial to ensure they are effective and do not cause discomfort or complications. Measuring the client's calf circumference helps in selecting the right size.

C. Applies lotion to the client's legs before putting on the stockings: This is an incorrect action. Applying lotion to the legs before putting on stockings can make the stockings less effective and may cause them to slide down. Lotions or creams can create a barrier that interferes with the compression provided by the stockings.

D. Rolls down the stockings from the thigh to the ankle: This is an incorrect action. Elastic antiembolic stockings should be applied carefully, starting at the ankle and rolling them up to the thigh. Rolling them down from the thigh to the ankle is not the correct technique, as it can impede blood flow and be uncomfortable for the client.

So, the correct answers are A and B. These actions indicate that the AP is performing the skill correctly by preparing the client appropriately and ensuring proper sizing of the stockings.

Choice A rationale:

The client does not need an oxygen mask for a low flow rate of 1 to 2 L/min. Oxygen masks are typically used for higher flow rates and may not be comfortable or necessary for a client requiring such a low oxygen flow.

Choice B rationale:

A reservoir bag is not required for a client receiving low flow oxygen at 1 to 2 L/min. Reservoir bags are commonly used with oxygen masks at higher flow rates to ensure a consistent supply of oxygen during inhalation.

Choice C rationale:

Petroleum jelly is not a necessary supply for a client prescribed home oxygen at 1 to 2 L/min. Its use may not be recommended due to the risk of flammability in the presence of oxygen.

Choice D rationale:

The correct choice is D. The client should have a nasal cannula as a supply upon discharge. A nasal cannula is the appropriate delivery device for low flow oxygen therapy at 1 to 2 L/min. It is comfortable and allows for adequate oxygen supplementation for the client.