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 C

Explanation

c. Hallucination

In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).

In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.

Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.

Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.

Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.

Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.

A. The client's foot feels cooler than in the previous assessment. B. The client's pedal pulse in the right foot is not palpable. C. The client's capillary refill time is 5 seconds in the toes. D. The client reports a pain level of 8 on a scale from 0 to 10.

Correct Answer is B

Explanation

The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood ﬂow to the limb.

The other options are also concerning and should be reported to the healthcare provider.

a) A cooler footmay indicate decreased blood ﬂow to the limb.

c) A capillary refill time of 5 secondsmay also indicate decreased blood ﬂow.

d) A pain level of 8 on a scale from 0 to 10should also be reported and addressed.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

Correct Answer is B

Explanation

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