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 D

Explanation

A. "You will be prescribed medication that will keep you well for years to come." This response provides false reassurance. Although medications can help manage angina, it does not guarantee that the client will not experience future complications.

B. "Do you have family members who died from heart disease?" This question may not address the client's immediate emotional needs and could come off as dismissive of the client's fear.

C. "You should discuss these worries with your physician." This statement redirects the client's concerns to the physician rather than addressing the client's emotional needs and fears in the moment.

D. "Tell me more about these fears." This response is therapeutic and encourages the client to express his concerns and feelings, which is a key part of addressing fear and anxiety.

A. Obtain platelet aggregation studies to confirm DVT B. Schedule deep tissue massage with physical therapy. C. Arrange for a venous duplex ultrasound. D. Monitor Homan's sign.

Correct Answer is C

Explanation

A. Obtain platelet aggregation studies to confirm DVT. Platelet aggregation studies are not used to diagnose deep vein thrombosis (DVT). They are more relevant for evaluating platelet function and clotting disorders.

B. Schedule deep tissue massage with physical therapy. Deep tissue massage is contraindicated in clients suspected of having DVT, as it could dislodge the clot and cause a pulmonary embolism or other complications.

C. Arrange for a venous duplex ultrasound. A venous duplex ultrasound is the standard diagnostic test used to confirm DVT. It visualizes the veins and assesses blood flow, helping to detect the presence of a clot.

D. Monitor Homan's sign. Homan’s sign (pain in the calf with dorsiflexion of the foot) was once considered a diagnostic indicator of DVT, but it is no longer considered reliable due to its low sensitivity and specificity. Therefore, it is not routinely used for DVT diagnosis.

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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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