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. The nurse wears an N95 respirator when performing client care: Measles is highly contagious and spreads through respiratory droplets. Wearing an N95 respirator provides appropriate respiratory protection for the nurse when caring for a client with measles. This action is appropriate and does not require intervention by the charge nurse.
B. The nurse places the client on airborne precautions: Measles is transmitted via airborne droplets, so placing the client on airborne precautions is necessary to prevent the spread of the disease to others. This action is appropriate and aligns with infection control guidelines.
C. The nurse ensures the client's room maintains a positive airflow: Positive airflow can potentially contribute to the spread of airborne pathogens outside the room, increasing the risk of transmission to others. For clients with airborne infections like measles, negative airflow rooms are required to minimize the risk of transmission to healthcare workers and other clients. Therefore, the charge nurse should intervene and correct this action.
D. The nurse has the client wear a mask for transport to radiology: Having the client wear a mask during transport helps minimize the spread of infectious droplets to others in the facility. This action is appropriate and aligns with infection control measures for airborne precautions
Correct Answer is D
Explanation
A. Chart a summary of the data at the change of the shift - Documenting a summary of data at the change of shift is appropriate for communication among healthcare providers but should not be the first action. It's important to document all relevant admission data promptly and accurately.
B. Note whether the client has a living will - While documenting the client's living will status is important for their care, it's not the first action to take during admission documentation. Immediate assessment and documentation of essential data related to the client's condition and history take priority.
C. Document the client's vital signs obtained by assistive personnel - Documenting vital signs obtained by assistive personnel is appropriate, but it should not be the first action. The nurse should first conduct a comprehensive assessment and document all relevant admission data.
D. Begin charting with an evaluation of the data - This is the most appropriate action. The nurse should start by evaluating and documenting the admission data systematically and comprehensively. This includes the client's chief complaint, medical history, allergies, current medications, vital signs, physical assessment findings, and any other pertinent information. Starting with an evaluation ensures that all relevant data are captured and documented accurately.
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