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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Emboli: Emboli can form as vegetations break off from the heart valves and travel to other parts of the body, causing complications such as stroke, pulmonary embolism, or organ infarction.
B. A heart murmur: A heart murmur is a common symptom of infective endocarditis but not a complication. It results from valve damage caused by the infection.
C. Petechiae: Petechiae are a manifestation of infective endocarditis, not a complication. They occur due to the damage to blood vessels by emboli or infection.
D. Fever: Fever is a common sign of infective endocarditis due to the ongoing infection but is not considered a complication.
Correct Answer is D
Explanation
A. Nitroglycerin: Nitroglycerin is used to relieve chest pain by dilating coronary arteries and increasing blood flow. However, in the immediate setting of a suspected MI, oxygen is prioritized to ensure adequate oxygenation.
B. Aspirin: Aspirin is essential in the early treatment of MI to prevent further clot formation by inhibiting platelet aggregation, but oxygen would still come first if the client’s oxygenation is compromised.
C. Morphine: Morphine is used for pain relief and to reduce anxiety and oxygen demand on the heart. However, it is administered after ensuring oxygen supply.
D. Oxygen: Oxygen should be administered first in a suspected myocardial infarction to ensure the heart and tissues receive adequate oxygen, especially if the patient is hypoxic.
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