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 A
Explanation
Answer: A. Physical assessment findings
Rationale: Physical assessment findings are relevant information for a physical therapist, as they provide information about the client's mobility, strength, balance, coordination, pain, and functional status.
Correct Answer is D
Explanation
A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
B.Applying water-soluble lubricant to the gastrostomy site routinely is not recommended because it can trap moisture, leading to maceration or infection.
C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
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