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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
This client has multiple risk factors for pancreatitis, including type 2 diabetes mellitus, hyperlipidemia, and a history of cardiovascular disease. Although the vital signs are relatively stable, the presence of risk factors and a likely clinical presentation (e.g., abdominal symptoms assumed by context) are consistent with pancreatitis. In acute pancreatitis, the pancreas becomes inflamed and digestive enzymes may attack pancreatic tissue.
NPO status is essential to rest the gastrointestinal tract and reduce pancreatic stimulation. Opioids are typically required due to the severity of abdominal pain. Elevated glucose can result from impaired insulin production due to pancreatic inflammation. Jaundice may occur if the bile duct is obstructed due to pancreatic swelling or inflammation.
Correct Answer is D
Explanation
A. Bulging anterior fontanel. A bulging fontanel is associated with increased intracranial pressure, not dehydration. Dehydration is more likely to cause a sunken fontanel.
B. Decreased temperature. Dehydrated infants typically exhibit normal or elevated temperatures, especially if they have an underlying infection or fever. A decreased temperature is not a common sign of dehydration.
C. Hypertension. Dehydration more commonly leads to hypotension or normal blood pressure, depending on severity. Hypertension is not an expected finding in an infant with fluid volume loss.
D. Oliguria. Decreased urine output (oliguria) is a classic and expected sign of dehydration in infants. It indicates the kidneys are conserving fluid due to inadequate intake and fluid loss from vomiting and diarrhea.
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