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 D
Explanation
A. The cause of death is typically determined and documented by the attending physician or coroner, not the nurse.
B.While this information might be included in other parts of the medical record prior to the death, it is not required in postmortem documentation.
C. The nurse should verify that advance directives were followed, but the actual copy of the advance directives does not need to be included in the postmortem documentation. These should already be part of the client’s medical record.
D. Documenting the location of the identification tag is important for proper identification of the body after death. This ensures that the body is correctly identified during transfer to the morgue or funeral home.
Correct Answer is D
Explanation
The correct answer is choiced. Route.
Choice A rationale:
The time of administration is typically specified in the prescription and does not usually require clarification unless there are specific concerns about timing with other medications or meals.
Choice B rationale:
The medication, erythromycin, is clearly specified in the prescription. There is no ambiguity about which medication is being prescribed.
Choice C rationale:
The dosage of 500 mg is clearly stated and is a standard dose for erythromycin. There is no need to clarify this unless there are specific patient concerns or conditions that might affect dosing.
Choice D rationale:
The route of administration (e.g., oral, intravenous) is crucial information that must be clarified if not specified.Erythromycin can be administered in multiple ways, and the effectiveness and side effects can vary depending on the route
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