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?

Determine if the stockings are binding.

Fold the top of the stocking over neatly.

Apply the stockings after the client is in a chair.

Massage the client's legs once every 8 hr while the stockings are in place.

Answer and Explanation

The Correct Answer is A

A. Determine if the stockings are binding. It is important to assess that antiembolic stockings are not too tight, especially around the top, as this can impair circulation. Proper fit ensures they function effectively to promote venous return and prevent deep vein thrombosis.
B. Fold the top of the stocking over neatly. Folding or rolling the tops can cause constriction and act like a tourniquet, reducing circulation and increasing the risk of complications such as venous stasis or skin breakdown.
C. Apply the stockings after the client is in a chair. Antiembolic stockings should be applied while the client is lying down, before getting up, to prevent blood pooling in the legs. Applying them after the client is upright may reduce their effectiveness.
D. Massage the client's legs once every 8 hr while the stockings are in place. Massaging the legs, especially in clients at risk for thrombosis, is not recommended as it could dislodge a clot and lead to embolism. Passive or active leg movement is safer and more effective.

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Correct Answer is D

Explanation

A. "Why are you eating seaweed soup?" This response is judgmental and dismissive of the client’s cultural practices. It can make the client feel misunderstood or disrespected.
B. "The hospital food is more nutritious for you." This statement is inaccurate and culturally insensitive, assuming that hospital food is superior without recognizing the nutritional and emotional value of traditional foods.
C. "Does the doctor know that you are eating that?" This implies unnecessary medical concern and may make the client feel like her personal choices require approval, which can be disempowering and disrespectful.
D. "Of course, I will heat that up for you." This response is supportive and culturally competent, respecting the client's traditions and preferences while promoting comfort and emotional well-being during the postpartum period.

A. Calories B. Folate C. Calcium D. Protein

Correct Answer is B

Explanation

A. Calories. Significant increases in caloric intake are not necessary during the first trimester. Most women do not require additional calories until the second and third trimesters, when fetal growth accelerates.
B. Folate. Folate (or folic acid) is crucial during early pregnancy, particularly in the first trimester, to prevent neural tube defects such as spina bifida. Women are advised to increase folate intake before conception and during early pregnancy.
C. Calcium. Calcium needs increase later in pregnancy when the fetus's bone development intensifies. While important throughout pregnancy, calcium is not the most critical nutrient to increase specifically in the first trimester.
D. Protein. Protein is essential for fetal growth, but increased protein needs become more important in the second and third trimesters when fetal tissue development peaks. Early pregnancy focuses more on folate supplementation for neural development.

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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

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