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 C

Explanation

The correct answer is C. Paranoid schizophrenia is a type of schizophrenia that involves delusions of persecution or conspiracy. The nurse should use therapeutic communication techniquesto empathize with the client's feelings and encourage them to express their thoughts without challenging or reinforcing their delusions. Therefore, stating that this must be very frightening for them and inviting them to talk more about it is an appropriate response that can help reduce anxiety and build trust. The other statements are not helpful or may be harmful. Asking why or what questions may imply doubt or disbelief in the client'sreality and provoke defensiveness or hostility. Contradicting or correcting the client's delusions may also increase their suspicion and resistance to treatment.

A. 7.5% B. 8.1% C. 13.3% D. 15%

Correct Answer is A

Explanation

To calculate the percentage of weight loss, we can use the formula:

Percentage of weight loss = (Weight loss / Original weight) * 100

Given that the client lost 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb), we can substitute these values into the formula:

Percentage of weight loss = (6.8 kg / 90.7 kg) * 100 Percentage of weight loss = 0.0749 * 100 Percentage of weight loss = 7.49%

The percentage of weight loss is approximately 7.49%.

Since none of the provided answer options exactly match this calculated percentage, the closest option is:

So, the nurse should identify the weight loss as approximately 7.5%.

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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 is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages?

Correct Answer is A

Explanation

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