A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves.
Which of the following actions should the nurse take?
Assist the patient into a prone position.
Place a sleeve over the top of each leg with the opening facing up.
Make sure two fingers can fit under the sleeves.
Set the ankle pressure at 65 mm Hg. .
The Correct Answer is C
Choice A rationale
Assisting the patient into a prone position is not necessary for the use of thigh-length sequential compression sleeves. These devices are typically used while the patient is in bed or sitting in a chair.
Choice B rationale
Placing a sleeve over the top of each leg with the opening facing up is not the correct method for applying sequential compression sleeves. The sleeves should be applied so that they fit snugly and comfortably around the patient’s legs.
Choice C rationale
The nurse should ensure that two fingers can fit under the sleeves. This is to ensure that the sleeves are not too tight, which could impede blood flow and cause discomfort or injury to the patient.
Choice D rationale
Setting the ankle pressure at 65 mm Hg is not related to the use of sequential compression sleeves. The pressure settings for these devices are typically determined by the healthcare provider based on the patient’s specific needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale
When a patient is placed on isolation precautions, the nurse should wear an N95 mask when caring for the patient. This is to protect the nurse from airborne particles that may be present in the patient’s environment.
Choice B rationale
Another important action the nurse should take is to place a container for soiled linens inside the patient’s room. This is to prevent the spread of infection from the patient’s room to other areas of the healthcare facility.
Choice C rationale
Wearing a sterile, water-resistant gown if within 3 feet of the patient is not necessary unless the patient has a condition that requires contact precautions, such as MRSA or VRE. In general, isolation precautions do not require the use of a sterile gown unless performing a sterile procedure.
Choice D rationale
Ensuring the patient’s room is well-ventilated is important for certain types of isolation precautions, such as airborne precautions for tuberculosis. However, it is not a standard action for all isolation precautions.
Correct Answer is D
Explanation
Choice A rationale
While showering frequency can vary depending on the specific isolation precautions, it does not indicate understanding of the protective isolation precautions.
Choice B rationale
Informing friends and family to visit when feeling well does not indicate understanding of protective isolation precautions. Protective isolation precautions are designed to protect the patient from infections, not based on how the patient is feeling.
Choice C rationale
Taking a plane to visit grandchildren does not indicate understanding of protective isolation precautions. Travel restrictions would depend on the specific condition and doctor’s advice.
Choice D rationale
Wearing a face mask when leaving the hospital room is a common requirement in protective isolation precautions to prevent the spread of infections.
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