A nurse is monitoring an assistive personnel (AP) who is applying elastic antiembolic stockings for a client who has phlebitis. Which of the following actions by the AP indicates that they are performing the skill correctly?

Rolls the extra stocking material down to the client's knee

Massages the legs before applying the stockings

Elevates the legs before applying the stockings

Positions the client in a chair before applying the stockings

Answer and Explanation

The Correct Answer is C

Elevating the legs helps to reduce swelling and promotes venous return, which is beneficial for a client with phlebitis. This action improves circulation and aids in preventing the formation of blood clots.

Rolls the extra stocking material down to the client's knee: This action is incorrect because elastic antiembolic stockings should be applied evenly and smoothly without any excess material. Rolling down the extra material can create folds and wrinkles, which can compromise the effectiveness of the stockings and potentially cause discomfort or impaired circulation.

Massages the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is not recommended. Massaging can stimulate blood flow and may dislodge any existing blood clots, posing a risk of embolism. It is important to handle the legs gently and avoid any aggressive or manipulative actions that can disturb the clots.

Positions the client in a chair before applying the stockings: Positioning the client in a chair before applying antiembolic stockings is not the correct action. It is preferable to have the client lie flat in a supine position, with the legs elevated, while applying the stockings. Lying flat helps improve venous return and ensures proper alignment and positioning of the stockings.

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Correct Answer is B

Explanation

b. Platelet count 90,000/mm3.

Explanation:

During pregnancy, it is important to monitor the client's platelet count because a low platelet count can indicate a condition called gestational thrombocytopenia or other potential complications such as preeclampsia or HELLP syndrome. A platelet count of 90,000/mm3 is lower than the normal range and should be reported to the provider for further evaluation and management.

Option a, Hgb 12 g/dL, falls within the normal range for hemoglobin during pregnancy, which is typically between 11-13.5 g/dL. Therefore, it does not require immediate notification to the provider.

Option c, Hematocrit 37%, also falls within the normal range for hematocrit during pregnancy, which is typically between 33-42%. Therefore, it does not require immediate notification to the provider.

Option d, Creatinine 0.7 mg/dL, is within the normal range for creatinine levels and does not indicate any immediate concerns or need for notification to the provider.

It is important to remember that the interpretation of laboratory results should be done in the context of the client's individual clinical presentation and the healthcare provider's assessment. Any concerns or abnormal findings should be communicated to the provider for further evaluation and appropriate management.

A. Allow the infant to have soft foods. B. Maintain elbow restraints on the infant. C. Instruct the parents to feed the infant with a spoon. D. Tell the parents to avoid brushing the infant's teeth for two weeks.

Correct Answer is B

Explanation

The nurse should include maintaining elbow restraints on the infant in the plan of care following cleft palate repair. This helps to prevent the infant from touching their surgical site and disrupting the healing process.

a) Allowing the infant to have soft foods may be appropriate, but it is not the highest priority. The infant's diet should be determined by the provider and based on the infant's individual needs.

c) Instructing the parents to feed the infant with a spoon may be appropriate, but it is not the highest priority. The infant's feeding method should be determined by the provider and based on the infant's individual needs.

d) Telling the parents to avoid brushing the infant's teeth for two weeks may be appropriate, but it is not the highest priority. The infant's oral care should be determined by the provider and based on the infant's individual needs.

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A nurse is monitoring an assistive personnel (AP) who is applying elastic antiembolic stockings for a client who has phlebitis. Which of the following actions by the AP indicates that they are performing the skill correctly?

Nursing Test Bank

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Explanation

A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse include?

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