A nurse is applying antiembolic stockings for a client who is postoperative. Which of the following actions should the nurse take?
Have the client point his toes before inserting his foot into the stocking.
Remove the stockings once every 24 hr.
Elevate the client's legs for 5 min prior to applying the stockings.
Roll the top of the stocking down so it fits snugly above the client's calf
The Correct Answer is C
A. Having the client point his toes before inserting his foot into the stocking is incorrect. The nurse should instruct the client to keep the foot in a neutral position to avoid unnecessary pressure on the toes or veins.
B. Removing the stockings once every 24 hr is incorrect. Antiembolic stockings should typically be removed and reapplied at least once per shift to allow for skin assessment and hygiene. They should not remain on for 24 hours continuously.
C. Elevating the client's legs for 5 min prior to applying the stockings is correct. Elevating the legs helps promote venous return by reducing swelling in the lower extremities. This makes the application of antiembolic stockings more effective and more comfortable for the client.
D. Rolling the top of the stocking down so it fits snugly above the client's calf is incorrect. The stockings should be applied smoothly and without folds to avoid restricting circulation. The top should not be rolled down as it can create pressure points
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Headaches with aura is correct. Headaches with aura, a warning sign that can precede a migraine, are a contraindication for the use of oral contraceptives. This is because oral contraceptives increase the risk of stroke, especially in women who experience migraines with aura.
B. History of mononucleosis 1 year ago is incorrect. There is no specific contraindication for oral contraceptives related to a history of mononucleosis. This condition does not affect the effectiveness or safety of oral contraceptive use.
C. Irregular menstrual cycles is incorrect. Irregular menstrual cycles are not a contraindication for oral contraceptive use. In fact, oral contraceptives may help regulate menstrual cycles.
D. Gastroesophageal reflux disease (GERD. is incorrect. While GERD may cause discomfort, it is not a contraindication for oral contraceptives. Women with GERD can typically use oral contraceptives safely.
Correct Answer is B
Explanation
A. Applying suction only during catheter removal is correct because continuous suction while inserting the catheter can cause tissue trauma and hypoxia. Intermittent suctioning during withdrawal prevents damage to the tracheal mucosa.
B. Suctioning for 30 seconds exceeds the recommended time limit, which is typically 10–15 seconds per pass for adults. Prolonged suctioning can cause hypoxia, bradycardia, and tissue trauma, making it unsafe for the client.
C. Preoxygenating with 100% oxygen before suctioning helps prevent hypoxia during the procedure. This is a standard safety measure to maintain adequate oxygen saturation levels.
D. Auscultating breath sounds before and after suctioning allows assessment of airway clearance and lung status. This step ensures that secretions have been effectively removed and helps identify any complications early.
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