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.

Answer and Explanation

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)

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Correct Answer is D

Explanation

Maintain sterile objects within the line of vision.

A. Hold hands folded below the waist after donning sterile gloves. This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.
B. Pick up and pour solutions with the palm of the hand covering bottle labels. This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.
C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.
D. Maintain sterile objects within the line of vision. This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.

A. "I can expect my eyelids to be bruised after this procedure.” B. "I will see dark spots in my vision after this procedure.” C. "I will receive general anesthesia for this procedure.” D. "I know the provider will replace the lens in my eyes during this procedure.”

Correct Answer is D

Explanation

Choice A rationale:

The statement, "I can expect my eyelids to be bruised after this procedure," indicates an understanding of the common side effects of cataract removal surgery. Bruising around the eyes is a common occurrence due to the manipulation of tissues during the procedure.

Choice B rationale:

The statement, "I will see dark spots in my vision after this procedure," is incorrect. Dark spots in vision are not a normal or expected outcome of cataract removal surgery. This statement shows a misunderstanding of the procedure.

Choice C rationale:

The statement, "I will receive general anesthesia for this procedure," is incorrect. While anesthesia is administered during the procedure, specifying the type of anesthesia is not crucial for the client's understanding of the surgery itself. The focus should be on the procedure details rather than the type of anesthesia.

Choice D rationale:

The statement, "I know the provider will replace the lens in my eyes during this procedure," indicates a clear understanding of the cataract removal procedure. The main goal of cataract surgery is to remove the cloudy lens and replace it with a clear artificial lens, improving the patient's vision. This statement demonstrates the client's comprehension of the surgery process.

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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?

Nursing Test Bank

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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?