A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolic stockings. Which of the following actions should the nurse take?
Measure the legs with a tape measure to determine stocking size.
Remove the stockings every 24 hr.
Massage the legs before applying the stockings.
Fold the stockings at the top if they are too long.
The Correct Answer is A
A. Measure the legs with a tape measure to determine stocking size: Antiembolic stockings should fit properly to provide therapeutic compression without causing discomfort or impairing circulation. Measuring the legs accurately with a tape measure ensures the stockings fit appropriately and exert the correct amount of pressure to prevent deep vein thrombosis (DVT) and promote venous return.
B. Remove the stockings every 24 hr: Antiembolic stockings are typically worn continuously, especially during periods of immobility, to maintain consistent compression and prevent blood clots. Removing the stockings every 24 hours would interrupt the therapeutic effect and increase the client's risk of developing DVT.
C. Massage the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is contraindicated, as it can dislodge blood clots and increase the risk of embolism. Additionally, massaging may cause trauma to the skin and exacerbate any existing circulatory issues.
D. Fold the stockings at the top if they are too long: Folding the stockings at the top if they are too long can create pressure points and compromise circulation, leading to discomfort and potentially exacerbating vascular issues. It is essential to ensure the stockings fit properly by selecting the appropriate size rather than folding them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Peanut butter: Peanut butter is typically thick and sticky, which can pose a choking hazard for individuals with dysphagia, especially if they have difficulty swallowing thicker textures. Therefore, peanut butter is not a suitable recommendation for a client with dysphagia.
B. Crispy rice bar: Crispy rice bars are often dry and crunchy, which can be challenging for individuals with dysphagia to swallow safely. Foods with dry or brittle textures can increase the risk of aspiration or choking, particularly in those with swallowing difficulties.
C. Scrambled eggs: Scrambled eggs are a suitable option for individuals with dysphagia, especially if they are prepared to a soft and moist consistency. Eggs are a good source of protein and can be easily modified to meet the texture requirements of a dysphagia diet. Soft and moist foods are generally safer for individuals with swallowing difficulties.
D. Soda crackers: Soda crackers are dry and crumbly, which can present a choking risk for individuals with dysphagia. Foods with a dry and crumbly texture should be avoided or modified to a safer consistency for individuals with swallowing difficulties. Therefore, soda crackers are not recommended for a client with dysphagia.
Correct Answer is B
Explanation
A. "A health care surrogate must be a family member.": This statement is incorrect. A health care surrogate, also known as a health care proxy or agent, does not necessarily have to be a family member. It can be any individual chosen by the client to make health care decisions on their behalf if they become unable to do so.
B. "The client can resume control of health care after a temporary loss of competency.": This statement demonstrates an understanding of advance directives. Advance directives allow individuals to maintain control over their health care decisions by specifying their preferences for treatment or appointing a surrogate decision-maker. If a client experiences a temporary loss of competency, they can regain control of their health care decisions once competency is restored.
C. "The provider will choose a client's health care surrogate.": This statement is incorrect. It is the responsibility of the client to choose their health care surrogate. While healthcare providers may provide guidance and information about advance directives, they do not choose the surrogate for the client.
D. "The provider can go against the client's wishes regarding advance directives.": This statement is incorrect. Advance directives are legally binding documents that express a client's wishes regarding medical treatment. Healthcare providers are generally obligated to follow the directives outlined in these documents, and they cannot go against the client's wishes unless certain legal exceptions apply, such as emergency situations where immediate action is required to preserve life.
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