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. "Verify the medication three times with the medication administration record.": This is the best practice for ensuring the correct medication is administered. The nurse should verify the medication when removing it from storage, before preparing the medication, and at the bedside before giving it to the patient to ensure the right drug, dose, patient, time, and route.
B. "Administer time-critical medication 60 min before or after the scheduled time.": Time-critical medications should be administered within a specified window of 30 minutes before or after the scheduled time, not 60 minutes. Administering medication too early or late could compromise its effectiveness.
C. "Identify the client by using one identifier before giving the medication.": The correct approach is to use two identifiers (e.g., name and date of birth) to verify the client's identity, not just one. This reduces the risk of medication errors.
D. "Document medication administration prior to administering medication.": Documentation should occur after medication administration, not before, to ensure accurate recordkeeping of the event.
Correct Answer is D
Explanation
A. Arms raised above her head with her legs elevated on pillows: This is not an appropriate position for a lumbar puncture. The positioning is not ideal for access to the lumbar region and would be uncomfortable for the client.
B. Prone with her arms at her side and her legs extended: While this position may be used for certain procedures, it is not the most appropriate position for a lumbar puncture, which requires specific spinal positioning to access the subarachnoid space effectively.
C. Trendelenburg with her body in Sims' position: Trendelenburg involves positioning the client with the head lower than the feet, which is not necessary for a lumbar puncture and could interfere with the procedure. The Sims' position is more suited for certain other procedures.
D. Head flexed to the chest and her knees pulled up to the abdomen: This is correct. The client should be in a fetal position, with the head flexed toward the chest and the knees pulled up toward the abdomen. This position helps to widen the intervertebral spaces and facilitates easier access for the lumbar puncture.
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