A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?
Check the capillary refill every 4 hrs
Compare the pedal pulses every 4 hrs
The Correct Answer is B
A. Check the capillary refill every 4 hrs Incorrect
The nurse should check capillary refill distally every 4 hr for a client whops elastic bandages on their lower extremities.
B. Compare the pedal pulses every 4 hrs CORRECT
The nurse should compare the pedal pulses bilaterally every week to check for adequate circulation for a client who has elastic bandages on their
lower extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "This can help prevent nausea." Turning, coughing, and deep breathing exercises are not primarily aimed at preventing nausea. These exercises are designed to maintain lung function and prevent respiratory complications.
B. "This can help prevent pneumonia." Correct. Turning, coughing, and deep breathing exercises are essential postoperative activities that help prevent the development of pneumonia by promoting lung expansion, clearing mucus, and preventing atelectasis.
C. "I should do this every 4 hours." The frequency of turning, coughing, and deep breathing exercises may vary based on individual client needs and surgical procedures. This statement does not demonstrate a specific understanding of the appropriate timing for these exercises.
D. "I should do this to keep my heart from beating too fast." Turning, coughing, and deep breathing exercises are not directly related to heart rate regulation. They are focused on lung expansion and airway clearance.
Correct Answer is C
Explanation
A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.
Capillary refill is assessed to evaluate peripheral perfusion.
B. Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C. Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D. Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.
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