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 A

Explanation

A. “Are you thinking of hurting yourself?”: This response directly and calmly assesses for suicidal ideation, which is essential when a client expresses feelings of worthlessness or passive death wishes. Asking clearly about self-harm allows the nurse to determine risk and initiate appropriate safety interventions.

B. “What would your family do without you?”: This response may increase guilt or emotional distress rather than encouraging open communication. It does not assess the client’s immediate safety or suicidal thoughts.

C. “When you get better you will not feel this way.”: This response minimizes the client’s current feelings and may make the client feel unheard or dismissed. It does not address potential suicidal risk or provide emotional support.

D. “Why would you think a thing like that?”: Asking “why” can sound judgmental and may discourage the client from sharing further. It does not assess for suicidal intent and may increase defensiveness or withdrawal.

A. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface. B. Open the side flap of the sterile kit, allowing it to lie flat on the work surface. C. Apply sterile gloves. D. Open the outermost flap of the sterile kit away from the nurse's body.

Correct Answer is D

Explanation

A. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface: Opening the flap closest to the nurse first increases the risk of contaminating the sterile field. The nurse’s arms and clothing could cross over the field, compromising sterility.

B. Open the side flap of the sterile kit, allowing it to lie flat on the work surface: Side flaps are opened after the flap farthest from the nurse. Opening side flaps prematurely can increase the chance of contaminating the sterile contents.

C. Apply sterile gloves: Sterile gloves are applied after the sterile field has been properly opened and prepared. Donning gloves before opening the sterile kit does not follow the correct sequence of steps.

D. Open the outermost flap of the sterile kit away from the nurse's body: Opening the flap farthest from the nurse first prevents reaching over the sterile field. This action helps maintain sterility and establishes a safe sterile field for the procedure.

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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?

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