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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Palpate the pulse distal to the cast: Assessing neurovascular status is the priority immediately after cast application. Palpating the distal pulse helps determine adequate circulation and can detect complications like compartment syndrome early, which can lead to permanent damage if untreated.

B. Position the casted extremity on a pillow: Elevating the extremity helps reduce swelling and pain, but it is a secondary action. Ensuring perfusion through a pulse check takes precedence before supportive comfort measures are initiated.

C. Place an ice pack over the cast: Cold therapy can help minimize swelling and pain in the initial hours after casting, but it should only be done after confirming that circulation is intact. Ice packs should also be used carefully to prevent moisture from damaging the cast.

D. Teach the client to keep the cast clean and dry: Education is important for long-term cast care, but it is not the immediate priority after application. Early assessment for circulation, sensation, and movement must occur first to ensure the cast has not compromised perfusion.

A. The client is tolerating clear liquids. B. The client is voiding at least 250 mL/hr. C. The client is maintaining bed rest. D. The client is consuming 1.000 calories daily.

Correct Answer is A

Explanation

Rationale:

A. The client is tolerating clear liquids: After gastric banding, clients typically start with clear liquids within the first 24–48 hours. Tolerating clear liquids at 36 hours post-op is an expected and desired outcome that indicates gastrointestinal recovery and readiness to progress the diet gradually.

B. The client is voiding at least 250 mL/hr: This urine output is abnormally high and could indicate diuresis or overhydration. The expected minimum urine output is around 30 mL/hr, so this value exceeds normal expectations and is not typical postoperatively.

C. The client is maintaining bed rest: Early ambulation is encouraged after bariatric procedures to prevent complications such as deep vein thrombosis or pulmonary embolism. Prolonged bed rest is not expected or recommended.

D. The client is consuming 1,000 calories daily: At 36 hours post-op, clients are still on a very restricted intake—usually clear liquids or small sips—and would not be consuming 1,000 calories. This intake would be excessive and inappropriate at this stage of recovery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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