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 A
Explanation
A: The Agency for Healthcare Research and Quality is a federal agency that conducts research on health care quality, access, and outcomes. It provides specific data on migrant farmworkers.
B: The National Institutes of Health is a federal agency that supports biomedical and behavioral research. It does not provide specific data on migrant farmworkers.
C: The Department of Agriculture is a federal agency that oversees agricultural production, food safety, nutrition, and rural development. It does not collects comprehensivedata on migrant and seasonal farmworkers, such as their demographics, health status, and access to health care.
D: The World Health Organization is an international organization that works to improve global health and coordinate responses to health emergencies. It does not provide specific data on migrant farmworkers in the United States.
Answer is:Department of Agriculture. The Department of Agriculture is a federal agency that oversees agricultural production, food safety, nutrition, and rural development.It also collects and publishes data on migrant and seasonal farmworkers, such as their demographics, health status, and access to health care1.
Statement is wrong because: Agency for Healthcare Research and Quality (AHRQ) is an independent agency within the U.S.Department of Health and Human Services that conducts research to improve the quality, safety, efficiency, and effectiveness of health care2.National Institutes of Health (NIH) is a federal agency that supports biomedical research and public health initiatives3. World Health Organization (WHO) is a specialized agency of the United Nations that is concerned with international public health.
Correct Answer is C
Explanation
- A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.
- B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.
- C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.
- D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.
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