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 B

Explanation

A. Perform the Credé’s maneuver. This technique, involving manual pressure on the bladder, is used to promote urination in clients with bladder retention. It is not appropriate for a client with a catheter and continuous bladder irrigation in place.
B. Maintain the irrigation solution rate. Pink-tinged urine is an expected finding 4 hours after a TURP as minor bleeding can occur. There is no need to adjust the irrigation rate unless clots form or the urine becomes bright red or obstructed.
C. Warm the irrigation solution. Warming the solution is not a standard intervention and does not directly manage postoperative bleeding or pink urine. Room temperature solution is typically used unless otherwise specified by the provider.
D. Replace the indwelling urinary catheter. There is no indication the catheter is malfunctioning or obstructed. Pink urine alone does not warrant replacement, and unnecessary catheter changes can increase infection risk.

A. Encourage a passive communication style. B. Publicly confront coworkers when conflict arises. C. Establish a strong employee code of conduct D. Focus on self-care

Correct Answer is D

Explanation

A. Encourage a passive communication style. Passive communication can lead to unresolved stress and burnout, as it prevents individuals from expressing their needs or concerns effectively. It is not a recommended strategy for managing compassion fatigue.
B. Publicly confront coworkers when conflict arises. Public confrontation can escalate tension and create a hostile work environment, which contributes to stress rather than alleviating it. Conflict should be addressed professionally and privately.
C. Establish a strong employee code of conduct. While a code of conduct is important for maintaining professional behavior, it does not directly address the emotional toll of compassion fatigue or promote personal well-being among staff.
D. Focus on self-care. Self-care is essential in preventing and managing compassion fatigue, which results from the emotional demands of caring for others. Encouraging activities that promote emotional, physical, and mental well-being helps staff maintain resilience and avoid burnout.

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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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