A nurse is monitoring an assistive personnel (AP) who is applying elastic antiembolic stockings for a client who has phlebitis. Which of the following actions by the AP indicates that they are performing the skill correctly?
Rolls the extra stocking material down to the client's knee
Massages the legs before applying the stockings
Elevates the legs before applying the stockings
Positions the client in a chair before applying the stockings
The Correct Answer is C
Elevating the legs helps to reduce swelling and promotes venous return, which is beneficial for a client with phlebitis. This action improves circulation and aids in preventing the formation of blood clots.
Rolls the extra stocking material down to the client's knee: This action is incorrect because elastic antiembolic stockings should be applied evenly and smoothly without any excess material. Rolling down the extra material can create folds and wrinkles, which can compromise the effectiveness of the stockings and potentially cause discomfort or impaired circulation.
Massages the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is not recommended. Massaging can stimulate blood flow and may dislodge any existing blood clots, posing a risk of embolism. It is important to handle the legs gently and avoid any aggressive or manipulative actions that can disturb the clots.
Positions the client in a chair before applying the stockings: Positioning the client in a chair before applying antiembolic stockings is not the correct action. It is preferable to have the client lie flat in a supine position, with the legs elevated, while applying the stockings. Lying flat helps improve venous return and ensures proper alignment and positioning of the stockings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
To elicit the Moro reflex, the nurse should clap hands after laying the newborn on a flat surface. The Moro reflex, also known as the startle reflex, is an involuntary motor response that infants develop shortly after birth. Loud noises and sudden movements can trigger a baby’s Moro reflex.
Option a is incorrect because turning the newborn's head quickly to one side while they are sleeping may not elicit the Moro reflex.
Option b is incorrect because placing a finger in the newborn's palm may elicit the grasp reflex, not the Moro reflex.
Option d is incorrect because holding the newborn upright with one foot touching the crib surface may not elicit the Moro reflex.
Correct Answer is D
Explanation
The first action the nurse should take is to reevaluate the client's response to the medication in 30 min. Hydromorphone has an onset of action of 15 to 30 minutes when taken orally ¹. Therefore, it may take some time for the medication to reach its full effect.
Option a is incorrect because it may not be necessary to contact the provider for more pain medication until after reevaluating the client's response to the medication.
Option b is incorrect because teaching relaxation techniques may not provide immediate relief for acute pain.
Option c is incorrect because documenting the client's reaction to the administration of medication should be done after reevaluating their response to the medication.
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