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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Submit an incident report to the risk manager: While reporting breaches of confidentiality may be necessary in some cases, the immediate priority is to stop the inappropriate discussion to prevent further violations. Filing an incident report can follow after addressing the situation.

B. Tell the APs to stop the conversation: The nurse should intervene immediately to maintain client confidentiality and comply with HIPAA regulations. Directly instructing the APs to stop the conversation prevents further exposure of private health information.

C. Document the event in the client's progress notes: Documentation in the client’s record is not appropriate for reporting staff breaches of confidentiality. Progress notes are for client care details, not staff behavior.

D. Inform the client of the APs actions: Informing the client is not the first step and could cause unnecessary distress. The priority is to address the staff behavior and maintain confidentiality.

A. Placement of a central venous catheter B. insertion of a nasogastric tube C. Administration of an iron injection using Z-track technique D. Irrigation of a wound with antibiotic solution

Correct Answer is A

Explanation

A. Placement of a central venous catheter: Inserting a central venous catheter is an invasive procedure with significant risks, including infection, bleeding, and pneumothorax. Informed consent is required to ensure the client understands the procedure, its risks, benefits, and alternatives before it is performed.

B. Insertion of a nasogastric tube: NG tube insertion is a common, low-risk procedure typically performed by nurses as part of routine care. It generally does not require formal informed consent, though verbal explanation and client cooperation are important.

C. Administration of an iron injection using Z-track technique: Administering an intramuscular injection is considered a routine nursing procedure. While clients should be informed about the medication and technique, formal written consent is not typically required.

D. Irrigation of a wound with antibiotic solution: Wound irrigation is a standard nursing intervention performed as part of routine care. It does not require formal informed consent, although the client should be informed about the procedure and purpose.

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Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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