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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Answer: C. Cleanse the client's meatus with antiseptic solution.

Rationale:

A. Lubricate the catheter with water-soluble gel:
While lubrication is an important step in the catheterization process, it is not the first action to take. Proper cleansing of the meatus is essential to minimize the risk of introducing bacteria into the urinary tract during the insertion of the catheter.

B. Position the sterile drape leaving the perineum exposed:
Setting up the sterile field is crucial, but the first priority should be to cleanse the meatus to prevent infection. The sterile drape should be positioned after ensuring the area is clean and before catheter insertion.

C. Cleanse the client's meatus with antiseptic solution:
This is the first action the nurse should take. Properly cleansing the meatus with antiseptic solution helps reduce the risk of urinary tract infections by eliminating bacteria from the area prior to catheter insertion. It is a critical step in maintaining aseptic technique during the procedure.

D. Attach a prefilled syringe to the catheter inflation hub:
Attaching the syringe for inflation is done after the catheter is inserted and positioned correctly. This action comes later in the procedure, once aseptic measures have been completed and the catheter is in place.

A. Performing a simple dressing change on a client's foot B. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile C. Providing postmortem care for a client who has recently died D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves

Correct Answer is B

Explanation

A. Performing a simple dressing change on a client's foot - This action is appropriate and within the scope of practice for assistive personnel.
B. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile - Handwashing with alcohol-based hand rub is not effective against Clostridium difficile spores. Proper hand hygiene for C. difficile requires washing with soap and water. The charge nurse should intervene to correct this action and ensure proper infection control procedures are followed.
C. Providing postmortem care for a client who has recently died - Providing postmortem care is within the scope of practice for assistive personnel and is appropriate.
D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves - This action is appropriate and within the scope of practice for assistive personnel.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Rationale:

A charge nurse is observing assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?

Correct Answer is B

Explanation

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