A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings.
Which of the following actions should the nurse take?
Massage the legs before applying the stockings.
Fold the stockings at the top if they are too long.
Measure the legs with a tape measure to determine stocking size.
Remove the stockings every 24 hr.
The Correct Answer is C
Choice A rationale:
Massaging the legs before applying the stockings is not advisable. Vigorous massage can dislodge clots in patients with DVT, leading to serious complications like pulmonary embolism. It is essential to handle the legs gently and follow the proper procedure for applying antiembolitic stockings.
Choice B rationale:
Folding the stockings at the top if they are too long is not recommended. Altering the stockings in this way can create uneven pressure, reducing their effectiveness in preventing DVT. It is crucial to choose the correct size of stockings to ensure proper compression and prevention of complications.
Choice C rationale:
Measuring the legs with a tape measure to determine the stocking size is the correct action. Proper sizing is essential to ensure the stockings fit the patient correctly and provide the appropriate level of compression. Ill-fitting stockings can be ineffective and may even cause harm, such as skin abrasions or impeded circulation.
Choice D rationale:
Removing the stockings every 24 hours is unnecessary unless there is a specific medical indication to do so. Continuous wear of antiembolitic stockings is generally recommended to provide consistent compression and prevent deep-vein thrombosis (DVT)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should include the statement, "Use a product with DEET on your skin and clothes when you are walking in a wooded area," in the educational program on Lyme disease. DEET is a widely used insect repellent effective against ticks. It is recommended to prevent tick bites in wooded and grassy areas. The rationale behind this choice is to educate the public about practical measures to reduce the risk of Lyme disease. DEET repels ticks, reducing the chances of tick attachment and, consequently, the transmission of Lyme disease.
Choice B rationale:
The statement, "Symptoms of Lyme disease appear 2 days after being bitten by an infected tick," is incorrect. The incubation period for Lyme disease can vary from 3 to 30 days after the tick bite. Symptoms usually appear within 3 to 14 days but can take longer to manifest. Providing inaccurate information can lead to misunderstanding and inadequate preventive measures.
Choice C rationale:
The statement, "Remove embedded ticks by squeezing the body with tweezers," is incorrect. Improper removal of ticks, such as squeezing the body, can lead to the injection of tick fluids into the host, increasing the risk of disease transmission. The correct method for tick removal is to use fine-tipped tweezers to grasp the tick as close to the skin's surface as possible and pull upward with steady, even pressure. This helps ensure the tick is removed entirely and reduces the risk of infection.
Choice D rationale:
The statement, "If bitten by a tick, testing for Lyme disease should occur within 2 weeks," is incorrect. Testing for Lyme disease immediately after a tick bite is not recommended because it takes time for the body to produce antibodies detectable by the tests. Testing too early can yield false-negative results. Healthcare providers may recommend testing if symptoms develop, but waiting for a few weeks after the bite increases the accuracy of the test results.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale:
Forming a committee of staff members to investigate current staffing issues is the first step the nurse manager should take. This is because it is important to understand the root cause of the problem before implementing any changes. The committee can gather data, identify patterns, and provide insights into why staffing for weekend shifts is a challenge. This could involve surveying staff members, reviewing shift patterns, and analyzing workload and patient acuity data. By involving staff members in the process, the nurse manager can ensure that the perspectives and experiences of those directly affected by the staffing issues are taken into account. This approach aligns with the principles of shared governance and participatory management, which have been shown to improve staff satisfaction and retention.
Choice B rationale:
While providing support to staff members who are resistant to staffing changes is an important part of change management, it is not the first step that should be taken. Resistance to change is often a symptom of deeper issues, such as lack of trust, poor communication, or perceived lack of fairness or respect. By first forming a committee to investigate the staffing issues (Choice A), the nurse manager can gain a better understanding of these underlying issues and address them directly. This can help to reduce resistance when changes are implemented.
Choice C rationale:
Scheduling a staff meeting to present different options to staff members is a key part of the change process, but it should not be the first step. Before presenting options, it is important to fully understand the problem and consider various possible solutions. This involves investigating the current staffing issues (Choice A) and potentially developing and evaluating different scheduling options. Once this has been done, the options can be presented to staff members for feedback and discussion.
Choice D rationale:
Giving staff members advance written notice of staffing changes is a crucial part of transparent and respectful communication. However, it is not the first step in addressing staffing issues. Before any changes can be announced, the nurse manager needs to understand the problem (Choice A), consider possible solutions, and involve staff members in the decision-making process (Choice C). Once a decision has been made, it should be communicated clearly and promptly to all staff members.
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