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A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?

Place the stockings on the client after the client ambulated to the restroom

Ensure the client's toes are visible after placing the stockings on the client

Measure the client's calf circumference and leg length from heel to knee.

After applying the stockings, place two fingers between the client's leg and stocking to check the fit.

Answer and Explanation

The Correct Answer is C

A. Place the stockings on the client after the client ambulated to the restroom.

Stockings should be applied before the client gets out of bed in the morning to prevent venous stasis and swelling.

B. Ensure the client's toes are visible after placing the stockings on the client.

Visible toes allow for monitoring of circulation, color, and temperature, which helps detect complications like restricted blood flow.

C. Measure the client's calf circumference and leg length from heel to knee.

Although the stocking should not constrict the toes, having them visible is not the primary indication of a proper fit. The focus is on ensuring proper compression around the calf and knee areas.

D. After applying the stockings, place two fingers between the client's leg and stocking to check the fit.

Unlike anti-embolism devices like TED hose, these stockings are meant to be snug to ensure adequate compression. The two-finger rule is more applicable to items like restraints, not compression stockings.

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Correct Answer is ["B","E"]

Explanation

A. Using the spreader bar to turn the patient.

The spreader bar is not designed for lifting or turning; it maintains cast shape and stability.

B. Protecting the cast from soiling.

Soiling the cast can lead to skin irritation and infection, especially in the perineal area.

C. Grasping the cast over the leg to help in turning.

This can cause pressure points or cast damage; turning should be done using proper support techniques.

D. Easing itching under the cast by scratching with a bent coat hanger.

This is unsafe and can cause skin injury or infection under the cast.

E. Turning frequently to the prone position.

Frequent position changes, including prone if tolerated, help prevent pressure sores and promote circulation.

A. True B. Maybe C. Perhaps D. False

Correct Answer is A

Explanation

A. True

Immobility can lead to urinary stasis, which increases the risk of urinary tract infections (UTIs). Monitoring for urinary symptoms is essential to detect these complications early.

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A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has a hip spica cast and will be discharged home to family. The nurse would include in the home education plan information relative to: (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

The nurse working with immobilized patients understands that monitoring for reports of pain with urination, changes in urination, and assessing fro frequency is essential in order to determine if an unwanted urinary problem is arising from her patient being immobile.

Correct Answer is A

Explanation

Mr. Milby is a 69-year-old patient who underwent a total knee replacement 3 days ago. The orders fro the continuous passive motion (CPM) machine are to set it at 45 degrees of flexion and 0 degrees of extension for Mr. Milby. Select all the options that need to be reported to the responsible nurse.

A nurse is collecting data from a client who has had paraplegia for several years. Which of the following physiologic changes due to immobility should the nurse consider when evaluating this client's overall status? (Select all that apply.)

A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client raising his arm from his side to above his head?

A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe hyperextension of the neck?

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

The nurse explains that range of motion exercises are necessary so that movement improves venous circulation by:

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further reinforcement of teaching?