A nurse is caring for a client who has a prescription for a sequential compression device (SCD). Which of the following actions should the nurse take when applying the SCD?
Place each sleeve under each leg with the opening at the calf.
Ensure two fingers fit between the leg and the sleeve.
Wrap excess tubing to the side of each leg.
Ensure pressure of the device is at 25 mm Hg.
The Correct Answer is B
A. Place each sleeve under each leg with the opening at the calf: This is incorrect; the correct placement is with the opening at the thigh and the sleeve wrapped around the entire leg.
B. Ensure two fingers fit between the leg and the sleeve: This is correct as it ensures that the SCD sleeve is properly fitted and not too tight, allowing for effective compression without restricting blood flow.
C. Wrap excess tubing to the side of each leg: This is incorrect because excess tubing should not be wrapped around the leg; it should be managed to avoid kinks and ensure proper functioning of the device.
D. Ensure pressure of the device is at 25 mm Hg: This is not specific enough for all devices; the pressure setting should be according to the manufacturer's guidelines and the client's needs, often ranging between 30 and 40 mm Hg for optimal effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I would like to see what this looks like today": This indicates effective coping as the client is engaging with their condition and facing the changes directly, which is an important step in emotional adjustment and recovery.
B. "I'm going to close my eyes until you are done dressing my incision": This suggests avoidance of the situation, which may indicate difficulty in coping with the reality of their condition.
C. "I would just like to spend my day staring at the TV": This may indicate withdrawal or avoidance, which is not an effective coping strategy.
D. "I'm planning to stay at home until my breast reconstructive surgery": While this may be part of the client's plan, it does not directly indicate effective coping with the current situation.
Correct Answer is C
Explanation
A. The medication reduces the rate at which the kidneys filter waste: This is incorrect as oxybutynin does not affect kidney function or the rate at which kidneys filter waste.
B. The medication decreases the sensitivity of the urethral sphincter: This is incorrect because oxybutynin primarily affects bladder muscle contraction, not the sensitivity of the urethral sphincter.
C. The medication prevents the bladder muscles from involuntarily contracting: This is correct as oxybutynin is an anticholinergic medication that reduces involuntary bladder contractions, leading to less frequent urination.
D. The medication blocks the nervous system impulse to produce urine: This is incorrect because oxybutynin works by blocking the action of acetylcholine in the bladder, not by blocking impulses to produce urine.
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