A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

Massage the client's legs once every 8 hr while the stockings are in place

Fold the top of the stocking over neatly

Determine if the stockings are binding

Apply the stockings after the client is in a chair.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Massage the client's legs once every 8 hr while the stockings are in place: Massaging the legs of a client at risk for thromboembolism is discouraged, as it could dislodge a clot and lead to a pulmonary embolism. Mechanical methods like stockings are preferred for promoting circulation.

B. Fold the top of the stocking over neatly: Folding the stockings creates a tourniquet effect, restricting venous return and potentially increasing the risk of venous stasis or skin breakdown. Stockings should remain flat and unfolded.

C. Determine if the stockings are binding: It’s important to assess for tightness, especially at the toes and calves, to ensure proper circulation and prevent pressure injuries. Stockings should fit snugly but not impair blood flow.

D. Apply the stockings after the client is in a chair: Stockings are most effective when applied while the client is in a supine position, before blood pools in the lower extremities. Delayed application reduces their preventive benefit.

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Correct Answer is ["A","B","D"]

Explanation

Rationale:

A. The client slept 5 hr the previous night: Restorative sleep reflects stabilization in manic episodes, where insomnia is a key symptom. Sleeping for five hours is a significant improvement, indicating reduced hyperactivity and improved mood regulation.

B. The client consumes 8 oz of high-calorie fluids each hour: Adequate nutritional intake and hydration are often compromised in mania due to distractibility and hyperactivity. Regular consumption of fluids shows enhanced attention, cooperation, and reduced psychomotor agitation.

C. The client takes short naps during the day: Napping during the day may actually signal persistent hyperactivity or fragmented sleep cycles. Restful, consolidated nighttime sleep is a better indicator of clinical improvement than sporadic daytime naps.

D. The client engages in quiet activities in their room: Participation in low-stimulation activities reflects improved impulse control, attention span, and reduced need for excessive stimulation positive signs of response to lithium and therapeutic interventions.

E. The client appears to listen to unseen others: Persistent auditory hallucinations suggest ongoing psychotic features. Although lithium can reduce mood-related psychosis, hallucinations at this stage indicate incomplete resolution of manic or psychotic symptoms.

A. SpO2 B. PH C. Respiratory rate D. Temperature

Correct Answer is B

Explanation

Rationale:

A. SpO₂: Although 88% is low for the general population, it is often an acceptable baseline for clients with COPD. Their oxygen saturation targets are typically between 88–92% to avoid suppressing respiratory drive, so this value may not require immediate provider notification.

B. pH: A pH of 7.22 indicates respiratory acidosis, which is a serious and potentially life-threatening complication of COPD. This level of acidosis shows that the client’s ventilation is inadequate, and immediate intervention is needed. This is the most critical finding that requires provider notification.

C. Respiratory rate: A rate of 22 breaths/min is slightly elevated but not critical. It may be compensatory and expected in a COPD patient who is hypoxic or retaining CO₂. By itself, it doesn't warrant urgent notification unless it worsens.

D. Temperature: A temperature of 37.2°C (99°F) is within the normal range and does not indicate infection or acute illness. It is not a finding that necessitates notifying the provider at this point.

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A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the client. Exhibits The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

ExhibitsA nurse is reviewing the medical record of a client who has COPD. The nurse should notify the provider about which of the following findings? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Correct Answer is B

Explanation

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