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 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.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.