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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Hearing voices is a common symptom of psychotic disorders, such as schizophrenia. The nurse should first assess if the client is at risk of harming themselves or others due to the content of the voices. This is a priority intervention that can help prevent potential violence or suicide. The other statements are not appropriate as initial responses. A walk outside may not stop the voices and may expose the client to more stimuli that could worsen their condition. Asking the client to listen to the nurse instead of the voices may be perceived as dismissive or challenging by the client. Acknowledging that the voices are real to the client but not to the nurse may help establish rapport, but it does not address the urgency of assessing for safety.
Correct Answer is C
Explanation
Choice A option:
Dietitian should not be consulted: The dietitian is an essential team member and will work closely with the client to ensure proper nutrition and dietary management. However, in the context of dysphagia, the speech-language pathologist's expertise is needed to determine safe swallowing strategies and food modifications.
Choice B option:
Physical therapist should not be consulted: The physical therapist focuses on maintaining and improving the client's physical function and mobility. While important in ALS management, the physical therapist's role is not directly related to the immediate issue of dysphagia.
Choice C option:
The speech-language pathologist is the correct answer because it specializes in assessing and treating communication and swallowing disorders. In this case, the speech-language pathologist is essential in evaluating the client's swallowing function, recommending appropriate dietary modifications (texture and consistency of foods), and implementing swallowing exercises or strategies to improve swallowing safety.
Choice D option:
Occupational therapist should not be consulted: The occupational therapist assists clients in regaining or maintaining independence in daily living activities. While the occupational therapist may address some aspects of mealtime activities and adaptive strategies, the speech-language pathologist is more specialized in evaluating and treating swallowing difficulties in clients with ALS.
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