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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A: Correct. Applying thromboembolic stockings (compression stockings) to the client's legs is a task that can be safely delegated to assistive personnel. The nurse should provide clear instructions on how to apply them properly.
B: Incorrect. Monitoring the circulation in all four extremities requires clinical judgment and skilled assessment, and it should not be delegated to assistive personnel.
C: Incorrect. Recording the condition of the client's skin requires observation and assessment, which should not be delegated to assistive personnel.

A. Full bounding pulse B. Cool extremities C. Moist crackles in the lungs D. Orthostatic hypotension E. Flat neck veins

Correct Answer is ["B","D","E"]

Explanation

A: A full bounding pulse is a sign of increased fluid volume or fluid overload, not fluid volume deficit.
B: Cool extremities can be an indication of decreased peripheral perfusion, which may occur in fluid volume deficit.
C: Moist crackles in the lungs are an indication of fluid volume excess or pulmonary congestion, not fluid volume deficit.
D: Orthostatic hypotension, which is a drop in blood pressure when changing from lying to standing, can be a sign of fluid volume deficit due to inadequate blood volume.
E: Flat neck veins are an indication of decreased venous return and can occur in fluid volume deficit.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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