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 B
Explanation
Rationale:
A. Perform the Credé’s maneuver: This manual technique is used to assist bladder emptying in clients with urinary retention due to neurogenic bladder. It is not appropriate or necessary when continuous bladder irrigation is in place and the catheter is draining.
B. Maintain the irrigation solution rate: Pink-tinged urine is expected during the early postoperative period following TURP, indicating mild bleeding. There is no need to adjust the irrigation rate unless there are signs of obstruction or bright red bleeding with clots.
C. Replace the indwelling urinary catheter: Catheter replacement is only necessary if there is a blockage or malfunction. In this case, the system appears to be functioning correctly, and there’s no indication of obstruction.
D. Warm the irrigation solution: Warming the irrigation fluid is not required and does not affect hematuria. The solution should be at room temperature unless otherwise prescribed. Hematuria at this stage is managed by monitoring, not fluid temperature changes.
Correct Answer is D
Explanation
Rationale:
A. Protamine: Protamine is used to reverse the effects of heparin, particularly in cases of heparin overdose or to stop excessive bleeding. It does not treat allergic reactions like urticaria.
B. Naloxone: Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression or overdose. It has no effect on histamine-mediated symptoms such as urticaria.
C. Hydralazine: Hydralazine is an antihypertensive medication that lowers blood pressure by relaxing arterial smooth muscle. It is not appropriate for managing allergic skin reactions.
D. Diphenhydramine: Diphenhydramine is an antihistamine that blocks histamine receptors, making it effective for treating allergic reactions such as urticaria (hives). It reduces itching, swelling, and redness caused by histamine release.
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