A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?
Massage the client's legs once every 8 hr while the stockings are in place
Fold the top of the stocking over neatly
Determine if the stockings are binding
Apply the stockings after the client is in a chair.
The Correct Answer is C
Rationale:
A. Massage the client's legs once every 8 hr while the stockings are in place: Massaging the legs of a client at risk for thromboembolism is discouraged, as it could dislodge a clot and lead to a pulmonary embolism. Mechanical methods like stockings are preferred for promoting circulation.
B. Fold the top of the stocking over neatly: Folding the stockings creates a tourniquet effect, restricting venous return and potentially increasing the risk of venous stasis or skin breakdown. Stockings should remain flat and unfolded.
C. Determine if the stockings are binding: It’s important to assess for tightness, especially at the toes and calves, to ensure proper circulation and prevent pressure injuries. Stockings should fit snugly but not impair blood flow.
D. Apply the stockings after the client is in a chair: Stockings are most effective when applied while the client is in a supine position, before blood pools in the lower extremities. Delayed application reduces their preventive benefit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Temperature 37.7° C (99.9° F): This temperature is only slightly elevated and not strongly indicative of infection. Endometritis typically presents with a fever above 38°C (100.4°F), reflecting a more pronounced inflammatory response.
B. Polyuria: Increased urine output is not a characteristic sign of endometritis. It may be seen with conditions such as diabetes mellitus or post-diuresis but is unrelated to uterine infection.
C. Malodorous lochia: Foul-smelling lochia is a key clinical sign of endometritis, indicating infection of the uterine lining. It often accompanies uterine tenderness, fever, and possibly abdominal pain.
D. Heart rate 56/min: Bradycardia is not typical in endometritis. Instead, clients may present with tachycardia as part of the systemic inflammatory response to infection. A low heart rate would be unexpected.
Correct Answer is C
Explanation
Rationale:
A. Rotate staff members caring for the client: Clients with paranoid personality disorder often struggle with trust and may become more suspicious if care is inconsistent. Assigning consistent staff helps build therapeutic rapport and minimizes perceived threats.
B. Mix the medication with the client’s food items: Covertly administering medications violates the client’s autonomy and can worsen paranoia if discovered. Open, honest communication is essential when working with clients who have paranoid thoughts.
C. Speak in a neutral tone when addressing the client: A neutral, calm, and nonjudgmental tone reduces perceived hostility or manipulation. It supports the development of trust and helps avoid triggering defensive or suspicious behaviors.
D. Limit the client’s opportunities to socialize with others: Social interaction should not be restricted unless it poses a safety risk. Encouraging appropriate socialization may help reduce isolation and reinforce reality, even if the client has difficulty with interpersonal relationships.
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