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
The Correct Answer is A
The action by the AP that indicates an understanding of the procedure is elevating the client's legs before applying the stockings. Elevating the legs can help reduce swelling and make it easier to apply the stockings.
Option b is incorrect because instructing the client to dorsiflex their feet while applying the stockings may not be necessary.
Option c is incorrect because massaging the client's legs before applying the stockings may not be necessary or appropriate.
Option d is incorrect because folding the top of the stockings over after applying them may not be necessary or appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A. Potassium
Rationale:
A) Potassium:
Furosemide is a loop diuretic that can cause significant potassium loss through increased urine output. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious cardiac arrhythmias and muscle weakness. Ensuring potassium levels remain within a normal range helps maintain the infant's overall health and safety while on this medication.
B) WBC Count:
While it is important to monitor WBC count in various clinical situations, furosemide does not typically affect white blood cell levels. Therefore, monitoring WBC count is not specifically indicated for infants receiving furosemide unless there is another underlying condition that requires it.
C) Iron:
Iron levels are not typically affected by furosemide. Monitoring iron levels would be more relevant in cases of anemia or other hematologic conditions. Furosemide does not interfere with iron metabolism, so this test is not a priority for infants on this medication.
D) Amylase:
Amylase is an enzyme related to the pancreas and is typically monitored in conditions such as pancreatitis. Furosemide does not have a direct effect on amylase levels, so monitoring this enzyme is not necessary for infants receiving this diuretic. The focus should be on electrolytes, particularly potassium.
Correct Answer is C
Explanation
A nurse reviewing the laboratory results of a client who has DKA should identify that the client's ABG results of pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L indicate metabolic acidosis. Metabolic acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a low bicarbonate level (less than 22 mEq/L).
The other options are not correct.
a) Respiratory alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a low PaCO₂ (less than 35 mm Hg).
b) Metabolic alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a high bicarbonate level (greater than 26 mEq/L).
d) Respiratory acidosisis an acid-base imbalance characterized by a low pH (less than 7.35) and a high PaCO₂ (greater than 45 mm Hg).
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