A nurse is preparing to apply a thigh-length sequential compression device for a client who is postoperative. Which of the following actions should the nurse take?
Wrap the sleeve loosely around the client's lower leg
Measure the circumference of the client's upper leg.
Turn on the mechanical unit prior to applying the sleeve
Position the client prone to apply the device.
The Correct Answer is B
A. Wrap the sleeve loosely around the client's lower leg: The sleeve should fit snugly but comfortably to ensure effective compression. Wrapping it too loosely reduces efficacy in promoting venous return and preventing deep vein thrombosis. Proper fit is essential for device function and patient safety.
B. Measure the circumference of the client's upper leg: Measuring the thigh circumference ensures the correct sleeve size is selected, which is crucial for effective compression and prevention of pressure injury. Accurate sizing allows the device to deliver appropriate pressure without causing discomfort or circulatory compromise.
C. Turn on the mechanical unit prior to applying the sleeve: The device should remain off until the sleeve is properly positioned on the client. Activating it beforehand may result in improper inflation, skin injury, or ineffective compression. Turning it on too early can also startle the client and reduce comfort.
D. Position the client prone to apply the device: The client should be supine or with legs slightly elevated when applying a thigh-length sequential compression device. Prone positioning is unnecessary, uncomfortable, and can complicate proper sleeve placement. Supine positioning facilitates correct alignment and device effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “I should practice pursed-lip breathing exercises.": This technique involves inhaling through the nose and exhaling slowly through pursed lips (as if whistling). This creates back-pressure in the airways, which keeps the bronchioles open longer during exhalation. This helps the client remove trapped carbon dioxide (CO2), reduces shortness of breath, and promotes relaxation.
B. "I will consume low-protein, low-calorie foods": Clients with COPD require adequate protein and calories to maintain muscle mass and energy for breathing. Restricting protein and calories could worsen muscle wasting and fatigue.
C. “I should do aerobic exercises once per day": While regular physical activity is beneficial, exercise should be paced and tailored to the client’s tolerance. Overexertion can exacerbate dyspnea and fatigue in COPD clients.
D. "I will increase my fluid intake to 1,700 milliliters per day.": While hydration is important to thin secretions, 1,700 mL is on the lower end of standard daily requirements for an adult. Clients with COPD are encouraged to drink 2 to 3 liters (2,000 to 3,000 mL) of fluid per day (unless contraindicated by heart failure) to help liquefy thick mucus, making it easier to cough up.
Correct Answer is A
Explanation
A. An assistive personnel is encouraging intake of oral fluids: For a client in the active dying phase, forcing or encouraging oral intake can cause discomfort, aspiration, or fluid overload. The focus should be on comfort rather than meeting standard hydration goals, so this requires intervention by the nurse.
B. Supplemental oxygen is in use: Oxygen may be provided for comfort if the client experiences dyspnea. Its use in the active dying phase is appropriate and does not require intervention unless it causes discomfort or is unnecessary.
C. Benzodiazepines are administered every 4 hr: Scheduled benzodiazepines can help manage anxiety, restlessness, or dyspnea in a dying client. This is an appropriate intervention for comfort and does not require nurse intervention.
D. A family member remains at the client's bedside 24 hr each day: Continuous presence of family provides emotional support and comfort for both the client and loved ones. This is consistent with hospice care principles and does not require nurse intervention.
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