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. Provide a diet high in protein and calories: Children with cystic fibrosis require increased caloric and protein intake due to higher metabolic demands and malabsorption. A high-protein, high-calorie diet supports growth and energy needs, helping to compensate for nutrient loss.

B. Trim the fat from red meat prior to cooking: Fat should not be unnecessarily restricted in the diet of a child with cystic fibrosis. These children need extra fat for energy, and fat-soluble vitamin absorption is often impaired despite enzyme replacement.

C. Give the child hot foods to reduce the sense of fullness: There is no evidence that temperature of food affects satiety in children with cystic fibrosis. The focus should remain on maximizing caloric intake, regardless of food temperature preferences.

D. Administer pancreatic enzymes 30 min after meals: Pancreatic enzymes should be given immediately before or with meals and snacks to aid digestion. Delaying administration reduces their effectiveness and can lead to malabsorption and gastrointestinal symptoms.

A. Coarse lung sounds B. Widening pulse pressure C. Muffled heart sounds D. Decreased jugular vein distention

Correct Answer is C

Explanation

Rationale:

A. Coarse lung sounds: Coarse lung sounds are typically associated with pulmonary issues such as fluid overload or pneumonia. They are not specific to cardiac tamponade and may appear later or not at all in this condition.

B. Widening pulse pressure: Cardiac tamponade causes narrowing of the pulse pressure due to decreased stroke volume, not widening. A narrowing pulse pressure is a more reliable hemodynamic sign of tamponade.

C. Muffled heart sounds: Muffled or distant heart sounds are a classic early sign of cardiac tamponade. They result from fluid accumulation in the pericardial sac, which insulates the heart and dampens the transmission of sound.

D. Decreased jugular vein distention: Cardiac tamponade typically causes increased jugular vein distention due to impaired venous return to the heart. A decrease in JVD would not be expected and may indicate a different process.

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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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Correct Answer is A

Explanation

A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?

Correct Answer is C

Explanation

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