A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves.
Which of the following actions should the nurse take?

Assist the patient into a prone position.

Place a sleeve over the top of each leg with the opening facing up.

Make sure two fingers can fit under the sleeves.

Set the ankle pressure at 65 mm Hg. .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Assisting the patient into a prone position is not necessary for the use of thigh-length sequential compression sleeves. These devices are typically used while the patient is in bed or sitting in a chair.

Choice B rationale

Placing a sleeve over the top of each leg with the opening facing up is not the correct method for applying sequential compression sleeves. The sleeves should be applied so that they fit snugly and comfortably around the patient’s legs.

Choice C rationale

The nurse should ensure that two fingers can fit under the sleeves. This is to ensure that the sleeves are not too tight, which could impede blood flow and cause discomfort or injury to the patient.

Choice D rationale

Setting the ankle pressure at 65 mm Hg is not related to the use of sequential compression sleeves. The pressure settings for these devices are typically determined by the healthcare provider based on the patient’s specific needs.

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Correct Answer is B

Explanation

Choice A rationale: Using a resuscitation bag with 80% oxygen prior to the procedure is inappropriate. While pre-oxygenation is important before suctioning to prevent hypoxia, the oxygen concentration should be 100%, not 80%. Normal oxygen saturation levels are 95% to 100%. Pre-oxygenating with 100% oxygen ensures the patient maintains adequate oxygenation during the brief suctioning period. Using 80% oxygen does not fully optimize oxygen reserves for this purpose.

Choice B rationale: Selecting a suction catheter that is half the size of the tracheostomy lumen is appropriate. This size prevents excessive occlusion of the airway, ensuring adequate airflow during suctioning. The correct catheter size minimizes trauma to the tracheal mucosa and prevents hypoxia. The catheter should not exceed 50% of the tracheostomy diameter to maintain proper airway function, making this the correct action for safe and effective suctioning.

Choice C rationale

Placing the end of the suction catheter in water-soluble lubricant is not recommended. This could introduce bacteria into the airway and increase the risk of infection.

Choice D rationale

Adjusting the wall suction apparatus to a pressure of 170 mm Hg is not correct. The recommended suction pressure for adults is usually between 80 and 120 mm Hg. Suctioning at too high a pressure can cause trauma to the airway.

A. “I could not arrive any sooner. What can I do for you?” B. “We had an emergency on the unit and that was a priority, but now I’m here.”. C. “That must be frustrating for you. How can I help you right now?”

Correct Answer is C

Explanation

Choice A rationale

Saying “I could not arrive any sooner. What can I do for you?” may come off as defensive and does not acknowledge the client’s feelings of frustration.

Choice B rationale

Saying “We had an emergency on the unit and that was a priority, but now I’m here.”. may make the client feel less important and does not acknowledge their feelings of frustration.

Choice C rationale

Saying “That must be frustrating for you. How can I help you right now?” acknowledges the client’s feelings of frustration and offers assistance, which is an appropriate response.

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A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves.Which of the following actions should the nurse take?

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A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves.
Which of the following actions should the nurse take?