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. Keep the affected knee flexed. Flexing the knee for prolonged periods can impede venous return and increase the risk of thrombosis. The knee should be extended, not flexed.

B. Encourage increased fluid intake. Encouraging fluid intake helps to prevent dehydration, which is a risk factor for blood clot formation. Adequate hydration helps keep the blood less viscous and reduces the risk of DVT.

C. Massage the client's calf on the affected side. Massaging the calf could dislodge a clot if one is present, leading to serious complications such as a pulmonary embolism. This is contraindicated.

D. Promote bed rest for 5-10 days. Early ambulation and movement are key to preventing DVT after surgery. Prolonged bed rest increases the risk of DVT due to venous stasis.

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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