A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

"They'll protect your legs and heels from skin breakdown."

"They'll make it easier for you to do leg exercises after your surgery."

They'll improve your circulation to keep blood from pooling in your legs."

"They'll help keep you warm immediately after your surgery."

Answer and Explanation

The Correct Answer is C

A. “They’ll protect your legs and heels from skin breakdown.”: While antiembolism stockings can provide some degree of protection against skin breakdown due to their snug fit, this is not their primary purpose. Their main function is to improve circulation and prevent blood clots, not to protect the skin.

B. “They’ll make it easier for you to do leg exercises after your surgery.”: Antiembolism stockings do not directly facilitate leg exercises. While they can help improve circulation which might indirectly aid in recovery, their primary purpose is to prevent the formation of blood clots in the lower extremities.

C. “They’ll improve your circulation to keep blood from pooling in your legs.”: This is correct. Antiembolism stockings, also known as compression stockings, are designed to apply pressure to your lower legs, helping to maintain blood flow and reduce discomfort and swelling. They can help prevent deep vein thrombosis (DVT), a type of blood clot that’s most common in the deep veins of your legs.

D. “They’ll help keep you warm immediately after your surgery.”: While antiembolism stockings might provide some warmth due to their material, this is not their primary function. Their main purpose is to improve circulation in the legs and prevent blood clots.

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Correct Answer is D

Explanation

A. Insert the IV catheter:

Inserting an IV catheter is necessary to administer IV fluids and medications. However, it is not the most immediate need. The priority is to address the client's oxygenation status first to stabilize them before proceeding with other interventions.

B. Obtain a blood sample:

Obtaining a blood sample for cardiac enzyme levels is important to diagnose a myocardial infarction. Nevertheless, this step should be taken after ensuring the client is receiving adequate oxygen, as hypoxia needs to be addressed immediately.

C. Attach the leads for a 12-lead ECG:

Attaching the leads for a 12-lead ECG is crucial for diagnosing the client's cardiac condition. However, it should be done after initiating oxygen therapy, as improving the client's oxygenation status is more urgent and can help stabilize the client for further diagnostic procedures.

D. Initiate oxygen therapy:

Initiating oxygen therapy is the most critical first action. The client is experiencing severe chest pain, shortness of breath, and signs of cyanosis, indicating that their oxygen levels are insufficient. Providing oxygen at 4 L/min via nasal cannula will help alleviate hypoxia, improve the client's condition, and provide time for further diagnostic and therapeutic interventions.

A. Restlessness B. Hyperactive bowel sounds C. Decreased deep-tendon reflexes D. Bounding peripheral pulses

Correct Answer is C

Explanation

A. Restlessness:

Restlessness is not typically associated with hypokalemia. Instead, it may indicate anxiety, discomfort, or other factors unrelated to electrolyte imbalances.

B. Hyperactive bowel sounds:

Hyperactive bowel sounds are often associated with increased gastrointestinal motility, which may occur in conditions such as diarrhea or gastroenteritis. While electrolyte imbalances can contribute to gastrointestinal symptoms, hyperactive bowel sounds are not specific to hypokalemia.

C. Decreased deep-tendon reflexes:

Hypokalemia can lead to decreased deep-tendon reflexes due to its effects on nerve conduction. Potassium is essential for proper nerve and muscle function, and low levels can impair reflexes.

D. Bounding peripheral pulses:

Bounding peripheral pulses are not typically associated with hypokalemia. Instead, they may indicate increased cardiac output or volume overload, which can occur in conditions such as heart failure.

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A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia?

Correct Answer is C

Explanation

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