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?

Determine if the stockings are binding.

Fold the top of the stocking over neatly.

Apply the stockings after the client is in a chair.

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

Answer and Explanation

The Correct Answer is A

A. Determine if the stockings are binding. It is important to assess that antiembolic stockings are not too tight, especially around the top, as this can impair circulation. Proper fit ensures they function effectively to promote venous return and prevent deep vein thrombosis.
B. Fold the top of the stocking over neatly. Folding or rolling the tops can cause constriction and act like a tourniquet, reducing circulation and increasing the risk of complications such as venous stasis or skin breakdown.
C. Apply the stockings after the client is in a chair. Antiembolic stockings should be applied while the client is lying down, before getting up, to prevent blood pooling in the legs. Applying them after the client is upright may reduce their effectiveness.
D. Massage the client's legs once every 8 hr while the stockings are in place. Massaging the legs, especially in clients at risk for thrombosis, is not recommended as it could dislodge a clot and lead to embolism. Passive or active leg movement is safer and more effective.

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Correct Answer is C

Explanation

A. Widening pulse pressure. This is typically associated with conditions like increased intracranial pressure or severe aortic regurgitation, not cardiac tamponade. Tamponade usually results in narrowed pulse pressure.
B. Coarse lung sounds. These may indicate fluid overload or pulmonary congestion, but they are not specific to cardiac tamponade and occur later or in different conditions.
C. Muffled heart sounds. This is a classic early sign of cardiac tamponade, caused by fluid accumulation in the pericardial sac, which dampens heart sounds on auscultation. It is part of Beck’s triad (muffled heart sounds, hypotension, and jugular vein distention).
D. Decreased jugular vein distention. In cardiac tamponade, jugular vein distention increases due to impaired venous return to the heart. Decreased JVD would be an unexpected finding in this condition.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

Tocolytic medication: Tocolytics are used to suppress preterm labor, which is not applicable for this postpartum client. There is no indication of uterine contractions needing suppression.
Intravenous antibiotic: The client exhibits signs of postpartum endometritis—including fever, uterine tenderness, foul-smelling lochia, and a very high WBC count (33,000/mm³). These findings strongly support the need for IV antibiotics to treat the infection.
Intrauterine tamponade balloon: This device is used for managing postpartum hemorrhage, which is not present in this case. The client’s lochia is moderate, not excessive, and her uterus is responding to massage.
Kleihauer-Betke test: This test is used to detect fetal-to-maternal hemorrhage, particularly in Rh-negative mothers after trauma or potential placental separation. It is not relevant in the context of postpartum infection.
Increase in daily fluid intake: The client is febrile and shows signs of systemic infection. Increased fluids support hydration, promote recovery, and help manage the effects of fever and infection, making this an appropriate supportive measure.

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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

A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?

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Explanation

A nurse on a postpartum unit is caring for a client. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate a provider's prescription for an dropdownanddropdown

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

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