A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolic stockings. Which of the following actions should the nurse take?
Measure the legs with a tape measure to determine stocking size.
Remove the stockings every 24 hr.
Massage the legs before applying the stockings.
Fold the stockings at the top if they are too long.
The Correct Answer is A
A. Measure the legs with a tape measure to determine stocking size: Antiembolic stockings should fit properly to provide therapeutic compression without causing discomfort or impairing circulation. Measuring the legs accurately with a tape measure ensures the stockings fit appropriately and exert the correct amount of pressure to prevent deep vein thrombosis (DVT) and promote venous return.
B. Remove the stockings every 24 hr: Antiembolic stockings are typically worn continuously, especially during periods of immobility, to maintain consistent compression and prevent blood clots. Removing the stockings every 24 hours would interrupt the therapeutic effect and increase the client's risk of developing DVT.
C. Massage the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is contraindicated, as it can dislodge blood clots and increase the risk of embolism. Additionally, massaging may cause trauma to the skin and exacerbate any existing circulatory issues.
D. Fold the stockings at the top if they are too long: Folding the stockings at the top if they are too long can create pressure points and compromise circulation, leading to discomfort and potentially exacerbating vascular issues. It is essential to ensure the stockings fit properly by selecting the appropriate size rather than folding them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Hold your daughter when your son first meets her." While it is important for the mother to hold the newborn during the first meeting with the older sibling, this option does not directly address the preschool-age son's potential reaction to the new baby.
B. "Plan for your son to meet his sister for the first time at home." Planning for the first meeting to occur at home is a common and appropriate strategy to help ease the transition for the older sibling. However, this option does not provide a specific strategy for helping the preschool-age son adjust to having a new sister.
C. "Give your son a little gift from his new sister." This is the most appropriate strategy to suggest. Offering a small gift from the new baby sister can help the preschool-age son feel included and special, fostering positive feelings toward the new sibling.
D. "Give your son plenty of 'alone time' with his sister." While encouraging bonding time between siblings is important, giving the older sibling plenty of alone time with the new baby may not be practical or feasible, especially in the early postpartum period when the mother requires assistance with caring for the newborn. Moreover, this option does not address the son's potential feelings of adjustment to having a new sister.
Correct Answer is D
Explanation
A. Hearing loss: While digoxin toxicity can affect various organ systems, including the auditory system, resulting in symptoms such as tinnitus (ringing in the ears), hearing loss is not a typical manifestation of digoxin toxicity.
B. Insomnia: Insomnia is not a common symptom of digoxin toxicity. Clients with digoxin toxicity are more likely to experience neurological symptoms such as confusion, visual disturbances, or changes in mental status.
C. Tachycardia: Digoxin toxicity can cause arrhythmias, but it typically presents with bradycardia rather than tachycardia. Bradycardia is a hallmark sign of digoxin toxicity due to its negative chronotropic effect on the heart.
D. Blurred vision: Blurred or yellow-tinted vision is a classic symptom of digoxin toxicity, often described as "yellow halos" around lights. Visual disturbances occur due to the drug's effects on the optic nerve and can progress to more severe manifestations, such as changes in color vision or photophobia. Therefore, blurred vision is a key indicator of digoxin toxicity and requires prompt assessment and intervention.
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