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. Malaise: Malaise is a common symptom of infective endocarditis, indicating generalized discomfort or fatigue. However, it is not an immediate life-threatening condition and does not require urgent intervention.

B. Dyspnea: Dyspnea is the priority because it can indicate heart failure or a pulmonary embolism, both of which are serious complications of infective endocarditis. This requires immediate attention and reporting.

C. Fever: Fever is common in infective endocarditis due to the underlying infection. While important, it is expected and usually managed with antipyretics and antibiotics. It is not as urgent as dyspnea.

D. Anorexia: Anorexia is also a common symptom of infective endocarditis but is not an immediate threat to the client’s health.

A. Fried fish sandwich and potato salad B. Baked turkey and salad C. Biscuits with sausage gravy and sliced tomatoes D. Barbecued ribs and canned baked beans

Correct Answer is B

Explanation

A. Fried fish sandwich and potato salad: Fried foods are high in unhealthy fats, which can increase cholesterol levels and are not recommended for clients after a myocardial infarction.

B. Baked turkey and salad: This is a healthy choice, as baked turkey is low in fat, and a salad provides nutrients without excessive fat or cholesterol, supporting heart health.

C. Biscuits with sausage gravy and sliced tomatoes: Biscuits and sausage gravy are high in saturated fats, which are not appropriate for a heart-healthy diet.

D. Barbecued ribs and canned baked beans: Barbecued ribs and canned baked beans may contain high levels of saturated fats, sugar, and sodium, which are not recommended for someone recovering from a myocardial infarction.

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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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Naxlex Comprehensive Predictor Exams

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