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. Provide frequent stimulation for the newborn: Newborns with neonatal abstinence syndrome (NAS) are often hypersensitive to stimuli. Excessive stimulation can worsen symptoms such as tremors, irritability, and sleep disturbances.
B. Decrease the lighting levels in the nursery: Reducing environmental stimuli such as bright lights and loud noises helps soothe infants with NAS. A calm, low-stimulation setting promotes comfort and minimizes overstimulation.
C. Wrap the newborn loosely in a blanket: Tight swaddling not loose wrapping is recommended for NAS to provide a sense of security and decrease tremors and agitation. Loose wrapping can increase distress and reduce effectiveness.
D. Encourage frequent eye contact with the newborn during feedings: Direct eye contact can be overstimulating for infants experiencing NAS. Instead, feedings should be calm and gentle, with minimal stimulation to reduce stress and improve tolerance.
Correct Answer is D
Explanation
Rationale:
A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected postoperatively and should be managed, but it does not indicate an immediate threat to tissue viability or life. It is not the top priority when compared to signs of stoma compromise.
B. The client refuses to look at the colostomy: Emotional adjustment is important and should be addressed with sensitivity, but it is a psychosocial concern rather than a physiological emergency. This can be prioritized after physical complications are ruled out.
C. The colostomy has had no output: Absence of output within the first 24 hours may be related to bowel manipulation during surgery. While it should be monitored, it is not as urgent as signs suggesting stoma necrosis or ischemia.
D. The stoma appears dark purple in color: A dark purple stoma indicates poor perfusion or possible necrosis, which is a surgical emergency. A healthy stoma should appear pink or red and moist. Immediate intervention is required to preserve tissue viability.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.