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. Mark the edges of steps: Marking the edges of steps with high-contrast tape or paint helps increase visibility and prevent falls for individuals with visual impairments.
B. Use low-wattage light bulbs: Using low-wattage light bulbs might reduce the brightness needed for safety. Higher-wattage bulbs or bright, energy-efficient lighting is usually recommended to improve visibility.
C. Place throw rugs over electrical cords: Placing throw rugs over electrical cords can create tripping hazards and is not a safe practice for individuals with visual impairments.
D. Leave doors slightly ajar: Leaving doors ajar can create obstacles and increase the risk of injury for someone with visual impairment, as they may not be able to detect the open door.
Correct Answer is C
Explanation
A. Intermittent abdominal pain: While abdominal pain may occur, it is not specifically related to total parenteral nutrition (TPN) and burn care.
B. Decreased calcium levels: Decreased calcium levels are not the primary concern with TPN. Calcium levels should be monitored, but other issues are more directly related to TPN.
C. Increased serum glucose levels: This is correct as TPN often contains high levels of glucose, which can lead to hyperglycemia. Monitoring serum glucose levels is crucial in managing TPN to avoid complications.
D. Absent bowel sounds: Bowel sounds are not directly affected by TPN. However, monitoring for gastrointestinal function is important in the overall assessment of the client.
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