A nurse is caring for a client who has a prescription for a sequential compression device (SCD). Which of the following actions should the nurse take when applying the SCD?
Place each sleeve under each leg with the opening at the calf.
Ensure two fingers fit between the leg and the sleeve.
Wrap excess tubing to the side of each leg.
Ensure pressure of the device is at 25 mm Hg.
The Correct Answer is B
A. Place each sleeve under each leg with the opening at the calf: This is incorrect; the correct placement is with the opening at the thigh and the sleeve wrapped around the entire leg.
B. Ensure two fingers fit between the leg and the sleeve: This is correct as it ensures that the SCD sleeve is properly fitted and not too tight, allowing for effective compression without restricting blood flow.
C. Wrap excess tubing to the side of each leg: This is incorrect because excess tubing should not be wrapped around the leg; it should be managed to avoid kinks and ensure proper functioning of the device.
D. Ensure pressure of the device is at 25 mm Hg: This is not specific enough for all devices; the pressure setting should be according to the manufacturer's guidelines and the client's needs, often ranging between 30 and 40 mm Hg for optimal effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}
Explanation
Heart rate
• Hypovolemic Shock
o The elevated heart rate of 104/min is consistent with hypovolemic shock, where the body compensates for reduced blood volume by increasing heart rate to maintain cardiac output and perfusion.
• Pulmonary Embolism
o An increased heart rate can also occur with pulmonary embolism as the body responds to decreased oxygenation and impaired cardiac function.
Respiratory effort
• Hypovolemic Shock
o Increased respiratory rate of 24/min may be a compensatory mechanism in hypovolemic shock to enhance oxygen delivery to tissues despite reduced blood volume.
• Pulmonary Embolism
o Elevated respiratory rate can also be seen in pulmonary embolism due to impaired gas exchange and increased respiratory effort to compensate for decreased oxygen levels.
Pain
• Pulmonary Embolism
o Pain, particularly pleuritic chest pain, is a common symptom of pulmonary embolism and could be indicative of embolic obstruction in the pulmonary circulation.
Blood pressure
• Hypovolemic Shock
o The drop in blood pressure to 88/54 mm Hg is consistent with hypovolemic shock, where reduced blood volume leads to decreased perfusion and hypotension.
Mentation
• Hypovolemic Shock
o Altered mentation, such as restlessness or agitation, can be a sign of hypovolemic shock as decreased perfusion affects brain function and consciousness.
• Pulmonary Embolism
o Changes in mentation can also occur in pulmonary embolism due to hypoxemia or decreased perfusion to the brain.
Correct Answer is C
Explanation
A. Presence of gag reflex: This is normal after a bronchoscopy as the gag reflex indicates that the client is recovering from sedation.
B. Sore throat: This is a common and expected finding after a bronchoscopy due to irritation of the throat.
C. Facial edema: This is correct as facial edema may indicate an allergic reaction or complication, and it should be reported to the provider immediately.
D. Blood pressure 110/78 mm Hg: This is within the normal range and does not typically require reporting unless there are other symptoms present.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.