A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Ensuring that creases in the stockings are on the front of the client's legs

Applying the stockings before the client gets out of bed

Asking the client to point their toes before applying the stockings

Turning the stockings inside out before applying them

Answer and Explanation

The Correct Answer is A

Choice A rationale:

This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.

Choice B rationale:

Applying the stockings before the client gets out of bed is correct. Antiembolic stockings should be applied before the client gets out of bed to prevent blood from pooling in the legs, which can help reduce the risk of deep vein thrombosis (DVT).

Choice C rationale:

Asking the client to point their toes before applying the stockings is a correct action. This helps in the proper fitting of the stockings and ensures they are applied smoothly without causing discomfort.

Choice D rationale:

Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.

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Correct Answer is B

Explanation

The correct answer is choice b. Performing indwelling urinary catheter care.

Choice A rationale:

Changing the appliance on a new colostomy is a complex task that requires assessment and education, which should be performed by a registered nurse (RN) or a licensed practical nurse (LPN).

Choice B rationale:

Performing indwelling urinary catheter care is a routine task that can be delegated to an assistive personnel (AP) as it involves basic hygiene and maintenance.

Choice C rationale:

Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient’s technique, which should be done by an RN or LPN.

Choice D rationale:

Measuring the depth of a stage 3 pressure injury requires assessment skills and clinical judgment, which are beyond the scope of practice for an AP. This task should be performed by an RN or LPN.

A. Increased urinary frequency B. Dry cough C. Metallic taste in mouth D. Excessive sweating

Correct Answer is D

Explanation

Choice A reason:

Increased urinary frequency Increased urinary frequency is not a typical adverse effect of sertraline. However, some individuals may experience changes in urinary habits due to various factors, but it is not directly related to sertraline use.

Choice B reason

Dry cough Dry cough is not a commonly reported adverse effect of sertraline. Cough is not a typical symptom associated with this medication.

Choice C reason

Metallic taste in the mouth While some individuals may experience changes in taste as a side effect of sertraline, a metallic taste in the mouth is not one of the commonly reported adverse effects. Taste changes are usually mild and temporary.

Choice D reason

Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant commonly used to treat conditions like depression, anxiety disorders, and obsessive-compulsive disorder. While most individuals tolerate sertraline well, it can cause certain adverse effects, and excessive sweating (also known as diaphoresis) is one of them.

Excessive sweating is a common side effect of sertraline and other SSRIs. It can manifest as increased sweating during the day or night, even in cooler environments. The degree of sweating can vary among individuals, and some may experience it more than others.

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A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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