A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse should identify that which of the following actions by the AP indicates an understanding of the procedure?

Elevates the client's legs before applying the stockings

Instructs the client to dorsiflex their feet while applying the stockings

Massages the client's legs before applying the stockings

Folds the top of the stockings over after applying them

Answer and Explanation

The Correct Answer is A

A. Elevates the client's legs before applying the stockings: Elevating the legs helps reduce venous pressure and promotes venous return, making it easier to apply the antiembolic stockings without causing constriction or discomfort. This step ensures the stockings fit smoothly and function effectively to prevent deep vein thrombosis.

B. Instructs the client to dorsiflex their feet while applying the stockings: While dorsiflexion exercises help stimulate circulation once the stockings are in place, instructing the client to dorsiflex during application is unnecessary and does not facilitate proper placement of the stockings.

C. Massages the client's legs before applying the stockings: Massaging the legs prior to applying stockings is contraindicated because it can dislodge a thrombus in clients at risk for deep vein thrombosis, potentially leading to a pulmonary embolism.

D. Folds the top of the stockings over after applying them: Folding the top of antiembolic stockings can create constriction, impair circulation, and reduce the stockings’ effectiveness. Stockings should be applied smoothly without wrinkles or folds to ensure uniform pressure and safety.

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Correct Answer is A

Explanation

A. Providing a ham and cheese sandwich to a client who follows a kosher diet: Kosher dietary laws prohibit pork and require specific food preparation. Giving a ham sandwich directly violates the client’s religious dietary restrictions and requires immediate correction and staff education to respect cultural and religious practices.

B. Giving peanut butter to a client who was prescribed a mechanical soft diet: A mechanical soft diet includes foods that are easy to chew and swallow. While crunchy peanut butter would be restricted, smooth peanut butter is typically allowed as it does not require significant mastication.

C. Offering ginger ale to a client who is a member of the Mormon faith: Ginger ale is nonalcoholic and caffeine-free options are usually available. Serving ginger ale is generally consistent with Mormon dietary restrictions, which prohibit alcohol and caffeinated beverages, so this does not require intervention.

D. Serving ice cream to a client who prescribed a full-liquid diet: Ice cream is considered a full-liquid food and is consistent with this diet order. It does not violate dietary guidelines, so no intervention is required.

A. Plan of care B. Graphic record C. Nurses' notes D. Discharge teaching

Correct Answer is B

Explanation

A. Plan of care: The plan of care is developed and updated by licensed nursing staff and other providers. Assistive personnel (AP) are not authorized to document assessments, interventions, or changes in the plan of care, as this requires professional judgment and accountability.

B. Graphic record: APs can document routine, objective data such as vital signs, intake and output, and other measurable observations in the graphic or flow sheet section of the EHR. This allows for accurate tracking of trends while remaining within their scope of practice.

C. Nurses' notes: Nurses’ notes require professional assessment, analysis, and evaluation of client responses to care. APs do not have the licensure to make these judgments, so they should not document in this section.

D. Discharge teaching: Documentation of discharge teaching reflects the nurse’s evaluation of client understanding and education provided, which is a licensed nursing responsibility. APs can reinforce teaching but are not authorized to document it as part of the official discharge record.

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A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse should identify that which of the following actions by the AP indicates an understanding of the procedure?

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