A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure the client's ankle circumference.

Measure from the client's heel to the gluteal fold.

Measure from the client's heel to the popliteal space.

Measure the length of the client's feet.

Answer and Explanation

The Correct Answer is C

A. Measure the client's ankle circumference. This is a correct action, as the ankle circumference is necessary to ensure that the stockings fit snugly and provide the proper amount of compression to prevent venous stasis.

B. Measure from the client's heel to the gluteal fold. This measurement would be appropriate for thigh-high stockings, not knee-high stockings.

C. Measure from the client's heel to the popliteal space. For knee-high stockings, measuring from the heel to the popliteal space (behind the knee) ensures the stockings fit properly without cutting off circulation or causing discomfort.

D. Measure the length of the client's feet. Foot length is not necessary for knee-high stockings, as their primary function is to apply compression from the ankle to the knee.

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Correct Answer is A

Explanation

A. Troponin T: Troponin T remains elevated for 10 to 14 days after a myocardial infarction. This protein is highly specific for cardiac muscle injury and is used to confirm myocardial infarction.

B. Creatinine phosphokinase: Creatinine phosphokinase (CPK) typically returns to normal levels within 3 days after a myocardial infarction, so it would no longer be elevated at this point.

C. Myoglobin: Myoglobin rises early after a myocardial infarction but is not specific to heart muscle and returns to normal within 24 hours, so it would not be elevated at this time.

D. Creatinine kinase-MB: Creatinine kinase-MB (CK-MB) usually returns to normal levels within 2 to 3 days after a myocardial infarction, so it is unlikely to still be elevated 6 days later.

A. "You will be prescribed medication that will keep you well for years to come." B. "Do you have family members who died from heart disease?" C. "You should discuss these worries with your physician." D. "Tell me more about these fears."

Correct Answer is D

Explanation

A. "You will be prescribed medication that will keep you well for years to come." This response provides false reassurance. Although medications can help manage angina, it does not guarantee that the client will not experience future complications.

B. "Do you have family members who died from heart disease?" This question may not address the client's immediate emotional needs and could come off as dismissive of the client's fear.

C. "You should discuss these worries with your physician." This statement redirects the client's concerns to the physician rather than addressing the client's emotional needs and fears in the moment.

D. "Tell me more about these fears." This response is therapeutic and encourages the client to express his concerns and feelings, which is a key part of addressing fear and anxiety.

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A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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