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.
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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Related Questions
Correct Answer is D
Explanation
A. "Why have you changed your mind about the surgery?" Asking "why" may sound accusatory and could cause the client to feel defensive. It's more effective to use therapeutic communication techniques that encourage open expression of feelings.
B. "Your provider would not have scheduled the surgery unless you needed it."This response minimizes the client's concerns and implies that their feelings are not valid, which can hinder communication.
C. "I will call your doctor and have him discuss your surgery with you." While involving the provider is important, this response deflects the client's concerns without first addressing their feelings or providing support.
D. "Bypass surgery must be very frightening for you." This response uses a therapeutic communication technique by acknowledging the client’s emotions and opening the conversation for further exploration of their concerns.
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.
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