A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure the client's ankle circumference.

Measure from the client's heel to the gluteal fold.

Measure from the client's heel to the popliteal space.

Measure the length of the client's feet.

Answer and Explanation

The Correct Answer is C

A. Measure the client's ankle circumference. This is a correct action, as the ankle circumference is necessary to ensure that the stockings fit snugly and provide the proper amount of compression to prevent venous stasis.

B. Measure from the client's heel to the gluteal fold. This measurement would be appropriate for thigh-high stockings, not knee-high stockings.

C. Measure from the client's heel to the popliteal space. For knee-high stockings, measuring from the heel to the popliteal space (behind the knee) ensures the stockings fit properly without cutting off circulation or causing discomfort.

D. Measure the length of the client's feet. Foot length is not necessary for knee-high stockings, as their primary function is to apply compression from the ankle to the knee.

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Correct Answer is B

Explanation

A. S3 heart sound: An S3 heart sound is often associated with heart failure and volume overload, not specifically mitral stenosis.

B. Dyspnea on exertion: Dyspnea on exertion is a classic symptom of mitral stenosis. The narrowing of the mitral valve restricts blood flow from the left atrium to the left ventricle, causing pulmonary congestion and shortness of breath, especially during physical activity.

C. Cyanosis: While cyanosis can occur in advanced stages of heart disease, it is not a primary symptom of mitral stenosis. It indicates severe oxygenation issues, which are usually late findings.

D. S4 heart sound: An S4 heart sound is typically associated with left ventricular hypertrophy, which can occur in advanced cases of mitral stenosis. However, it's not a specific early manifestation of the condition.

A. "It usually takes at least 2 to 3 days for heparin to dissolve a clot." B. "Heparin prevents new cloth from forming rather than dissolving established clots." C. "The time it takes for heparin to dissolve a clot depends on the size of the clot." D. "The time it takes heparin to dissolve clots varies between clients."

Correct Answer is B

Explanation

A. "It usually takes at least 2 to 3 days for heparin to dissolve a clot." Heparin does not dissolve clots; it prevents the formation of new clots and stops existing clots from growing.

B. "Heparin prevents new clots from forming rather than dissolving established clots." Heparin's role is to prevent new clots from forming, not to dissolve existing clots. The body's natural fibrinolytic system will eventually break down the clot.

C. "The time it takes for heparin to dissolve a clot depends on the size of the clot." This is incorrect because heparin does not dissolve clots, regardless of their size.

D. "The time it takes heparin to dissolve clots varies between clients." This is incorrect as well, as heparin does not dissolve clots at all.

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A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

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