A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings.
Which of the following actions should the nurse take?
Massage the legs before applying the stockings.
Fold the stockings at the top if they are too long.
Measure the legs with a tape measure to determine stocking size.
Remove the stockings every 24 hr.
The Correct Answer is C
Choice A rationale:
Massaging the legs before applying the stockings is not advisable. Vigorous massage can dislodge clots in patients with DVT, leading to serious complications like pulmonary embolism. It is essential to handle the legs gently and follow the proper procedure for applying antiembolitic stockings.
Choice B rationale:
Folding the stockings at the top if they are too long is not recommended. Altering the stockings in this way can create uneven pressure, reducing their effectiveness in preventing DVT. It is crucial to choose the correct size of stockings to ensure proper compression and prevention of complications.
Choice C rationale:
Measuring the legs with a tape measure to determine the stocking size is the correct action. Proper sizing is essential to ensure the stockings fit the patient correctly and provide the appropriate level of compression. Ill-fitting stockings can be ineffective and may even cause harm, such as skin abrasions or impeded circulation.
Choice D rationale:
Removing the stockings every 24 hours is unnecessary unless there is a specific medical indication to do so. Continuous wear of antiembolitic stockings is generally recommended to provide consistent compression and prevent deep-vein thrombosis (DVT)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Almonds are not typically associated with latex allergy or cross-sensitivity. Latex cross-reactivity is more commonly seen with certain fruits such as bananas, avocados, kiwis, and chestnuts.
Choice B rationale:
Bananas are known to be cross-reactive with latex allergy. Individuals allergic to latex are more likely to have allergies to certain fruits, including bananas. This cross-sensitivity occurs due to the structural similarity between latex proteins and proteins found in these fruits.
Choice C rationale:
Hazelnuts are not commonly associated with latex cross-reactivity. While some individuals with latex allergy may also be allergic to hazelnuts, it is not a high-risk food in the context of latex cross-sensitivity.
Choice D rationale:
Strawberries are not typically associated with latex allergy or cross-reactivity. Latex cross-reactivity is more commonly seen with fruits like bananas, avocados, kiwis, and chestnuts. Strawberries are not among the high-risk foods for individuals with latex allergy.
Correct Answer is B
Explanation
A is incorrect because the completion of the incident report should not be documented in the client's medical record, but in a separate file for quality improvement purposes.
B is correct because the time the medication was given is an essential fact related to the incident that should be documented in the client's medical record.
C is incorrect because the reason for the medication error should not be documented in the client's medical record, but in the incident report for analysis and prevention of future errors.
D is incorrect because the notification of the pharmacist should not be documented in the client's medical record, but in the incident report for follow-up and corrective actions.
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