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 C

Explanation

Rationale:

A. Instruct the client to be NPO for six hours prior to the procedure: Amniocentesis is typically done under local anesthesia and does not require sedation or general anesthesia, so there is no need for the client to be NPO beforehand.

B. Instruct the client to maintain a full bladder for the procedure: A full bladder is required during early pregnancy to help lift the uterus for better visualization. However, at 22 weeks gestation, the uterus is already an abdominal organ, and a full bladder is not necessary.

C. Monitor the fetal heart rate prior to the procedure: Monitoring the fetal heart rate before an amniocentesis is essential to establish a baseline and ensure fetal well-being. It also aids in identifying any immediate changes following the procedure.

D. Place the client in Trendelenburg position during the procedure: The Trendelenburg position is not appropriate for amniocentesis. The client is typically placed in a supine or slightly tilted position to allow proper access to the uterus and avoid vena cava compression.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices:

Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.

Rationale for Incorrect Choices:

Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
Blood glucose level: Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.

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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

A nurse is planning care prior to an amniocentesis for a client who is at 22 weeks of gestation. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse in a medical-surgical unit is caring for a clent Exhibits Complete the following sentence by using the lists of options. The nurse should first address the dropdown followed by the client dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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