A nurse is supervising an assistive personnel (AP. who is applying anti-embolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?
Applying the stockings before the client gets out of bed
Turning the stockings inside out before applying them
Asking the client to point their toes before applying the stockings
Ensuring that creases in the stockings are on the front of the client's legs
The Correct Answer is D
The nurse must intervene if the AP leaves creases or folds in the stockings because wrinkles and creases create uneven pressure points that can restrict blood flow and irritate the skin. Anti-embolic stockings are designed to provide smooth, graduated compression to promote venous return; any bunching or folding defeats this purpose and increases the risk of skin breakdown or thrombus formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceb. Support the client’s decision to stop the treatment.
Choice A rationale:
While discussing the decision with family can be important, the nurse’s primary responsibility is to respect and support the client’s autonomy and decision-making capacity. Encouraging the client to discuss with family is secondary to supporting their decision.
Choice B rationale:
Supporting the client’s decision to stop treatment respects their autonomy and right to make decisions about their own care.This is a fundamental principle in nursing ethics and patient-centered care.
Choice C rationale:
Discussing alternative treatment methods may be appropriate in some contexts, but in this case, the client has already made a decision to stop dialysis. The nurse should focus on supporting this decision rather than suggesting alternatives.
Choice D rationale:
Asking the facility chaplain to visit the client can be supportive, but it should not be the nurse’s primary action. The nurse should first support the client’s decision and then offer additional support services as needed.
Correct Answer is C
Explanation
A. Incorrect. Irrigation of a wound with antibiotic solution typically does not require informed consent.
B. Incorrect. Insertion of a nasogastric tube does not usually require informed consent unless it involves specific risks or is part of a research protocol.
C. Correct. Placement of a central venous catheter is an invasive procedure that involves risks, and informed consent is usually required.
D. Incorrect. Administration of an iron injection using the Z-track technique is a routine procedure and does not usually require informed consent.
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