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 B
Explanation
Choice A reason:
Discarding the first 10 mL of urine is a common practice for obtaining a urine sample for certain tests, but it is not specifically necessary for a urine culture. In a urine culture, the goal is to obtain a sample directly from the bladder to identify any bacteria present, so discarding the initial urine is not necessary.
Choice B reason
Donning sterile gloves prior to the procedure is the appropriate action for the nurse to take. When catheterizing a toddler for a urine culture, it is essential to maintain a sterile procedure to reduce the risk of infection and ensure the safety of the child. Using sterile gloves is a crucial step in preventing contamination during the catheterization process.
Choice C reason
The size of the catheter (12-French) mentioned in option C may not be appropriate for a toddler. The size of the catheter used for a toddler would generally be smaller, depending on the age and size of the child. The appropriate catheter size should be determined based on the child's age and condition.
Choice D reason
EMLA cream is a topical anaesthetic cream used to numb the skin before certain procedures. While it might be appropriate in some cases, it is not typically used for catheterization procedures in toddlers. Catheterization is a quick procedure, and using EMLA cream may not be necessary or practical in this situation.
Correct Answer is D
Explanation
The correct answer is D. Roasted salmon. A kosher diet is based on Jewish dietary laws that prohibit certain foods and combinations of foods. Some of these rules include avoiding pork, and shellfish, and mixing meat and dairy products. Therefore, shrimp salad, pulled pork sandwich, and clam chowder are all non-kosher menu items that should be avoided by a
client who follows a kosher diet. Roasted salmon is a kosher menu item that can be included on the tray, as long as it is not served with any dairy products or non-kosher ingredients.
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