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 D

Explanation

A. Able to unzip a zipper. This fine motor skill typically develops closer to age 2 to 3 years. At 15 months, most toddlers do not yet have the dexterity required to manipulate clothing fasteners.
B. Builds a tower of 4 cubes. A 15-month-old can usually build a tower of 2 to 3 cubes, while building a tower of 4 or more cubes is more typical around 18 to 24 months.
C. Throws a ball without falling. While some toddlers may attempt to throw a ball, doing so without falling is more characteristic of children around 18 months or older as balance improves.
D. Walks without help. This is an expected milestone by 12 to 15 months. Most toddlers at 15 months are able to walk independently, though gait may still be wide-based and unsteady.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

Dry skin and lips: This is a very common side effect of isotretinoin due to its drying effects on sebaceous glands. It is expected and manageable with regular moisturizing and is not considered an emergency.
Increased appetite: Isotretinoin is not associated with increased appetite. Weight changes are not typical or concerning symptoms during therapy and do not warrant urgent provider notification.
Depression: Isotretinoin has been associated with mood changes including depression, suicidal thoughts, and other psychiatric effects. These can emerge suddenly and must be reported immediately for prompt evaluation and intervention to ensure safety.
Visual disturbances: Blurred vision or difficulty seeing, particularly at night, can indicate rare but serious complications such as increased intracranial pressure. Any change in vision during isotretinoin therapy requires immediate medical attention.
Productive cough: This is not commonly linked with isotretinoin therapy. Unless respiratory symptoms worsen or are accompanied by fever or systemic signs, a productive cough alone is not a reason to stop treatment or alert the provider urgently.

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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

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Explanation

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

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