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.
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Related Questions
Correct Answer is C
Explanation
A. "You will not become fatigued when you use assistive devices": This is incorrect as clients may still experience fatigue even with assistive devices, and energy conservation strategies should be discussed.
B. "Plan to hire a home care aide to perform all of your ADLs": This is not advisable as the goal is to encourage as much independence as possible; assistance should be provided based on need, not all tasks.
C. "Install grab bars in your shower to assist with your balance": This is correct as installing grab bars can enhance safety and support the client’s balance, helping to prevent falls and injuries.
D. "Place a towel in the shower to prevent slipping": This is not as effective as grab bars and may not provide adequate support or prevent slips as well as proper bathroom modifications.
Correct Answer is D
Explanation
A. Offer snacks that are high in sodium: This is incorrect as high sodium intake can exacerbate heart failure by increasing fluid retention and worsening symptoms.
B. Place the head of the client's bed flat: This is incorrect because elevating the head of the bed helps reduce shortness of breath and improves comfort in heart failure patients.
C. Monitor the client's weight once per week: This is incorrect; daily weight monitoring is recommended to detect fluid retention or loss, which can be critical in managing heart failure.
D. Provide rest periods throughout the day: This is correct as providing rest periods helps manage fatigue and reduce the workload on the heart, which is important in heart failure management.
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