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. The stockings prevent venous stasis. Antiembolism stockings help prevent venous stasis by promoting venous return from the legs to the heart, which helps reduce the risk of deep vein thrombosis (DVT).

B. The stockings prevent varicose veins. Antiembolism stockings are not specifically used to prevent varicose veins. They are primarily used to prevent blood clots and improve circulation after surgery.

C. The stockings replace the need for postoperative leg exercises. Antiembolism stockings do not replace the need for leg exercises. Movement and exercise are still necessary to promote circulation and prevent DVT.

D. The stockings are used to reduce pain. Antiembolism stockings are not designed to reduce pain. Their main purpose is to prevent blood clots and improve circulation.

A. Malaise B. Dyspnea C. Fever D. Anorexia

Correct Answer is B

Explanation

A. Malaise: Malaise is a common symptom of infective endocarditis, indicating generalized discomfort or fatigue. However, it is not an immediate life-threatening condition and does not require urgent intervention.

B. Dyspnea: Dyspnea is the priority because it can indicate heart failure or a pulmonary embolism, both of which are serious complications of infective endocarditis. This requires immediate attention and reporting.

C. Fever: Fever is common in infective endocarditis due to the underlying infection. While important, it is expected and usually managed with antipyretics and antibiotics. It is not as urgent as dyspnea.

D. Anorexia: Anorexia is also a common symptom of infective endocarditis but is not an immediate threat to the client’s health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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