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

Answer and Explanation

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.

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Correct Answer is B

Explanation

b. Migraines with aura.

Explanation:

Migraines with aura are considered a contraindication to the use of oral contraceptives. Auras are neurological symptoms that occur before or during migraines and can include visual disturbances, sensory changes, or speech difficulties. Women who experience migraines with aura have an increased risk of ischemic stroke when taking oral contraceptives. Therefore, it is important to identify this condition as a contraindication and explore alternative contraceptive options for the client.

The other options (a. History of renal calculus, c. BMI of 25, d. History of cholecystectomy) are not contraindications to the use of oral contraceptives.

A. Ask the client to help with the dressing change B. Wait for the client to approach the nurse for assistance C. Use paper tape for securing the new dressing D. Apply the dressing loosely over the incision

Correct Answer is C

Explanation

Rationale:

A. Asking the client to assist with a surgical dressing change following a total hip arthroplasty may be inappropriate due to the client's postoperative physical limitations and hip precautions. While fostering independence is generally positive, it does not specifically address the physiological age-related changes of the integumentary system. The primary concern in this scenario is protecting the integrity of the client's fragile skin during adhesive removal.

B. Waiting for a client to request assistance for a scheduled postoperative dressing change is a deviation from the standard plan of care and proactive nursing management. Postoperative wound care is a scheduled clinical priority to monitor for infection and promote healing. This action does not demonstrate sensitivity to age-related physiological changes and could potentially lead to delayed detection of surgical site complications or wound dehiscence.

C. Using paper tape is the most appropriate action because older adults possess a thinner stratum corneum and diminished cohesion between the dermis and epidermis. Traditional plastic or silk adhesives can cause epidermal stripping and skin tears upon removal due to their high tackiness. Paper tape provides sufficient securement for the surgical dressing while minimizing the risk of mechanical injury to the sensitive, translucent skin of an elderly patient.

D. Applying a dressing loosely over a fresh surgical incision is contraindicated as it fails to provide an adequate microbial barrier and does not support wound healing. A loose dressing may shift, causing friction against the incision line or allowing contaminants to reach the surgical site. To demonstrate age-related sensitivity, the nurse must ensure the dressing is secure while using materials that are gentle on the surrounding atrophic skin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who is requesting an oral contraceptive. Which of the following findings should the nurse identify as a contraindication to the use of oral contraceptives?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The nurse is preparing to change the client's surgical dressing. Which of the following actions should the nurse take to demonstrate sensitivity to age-related changes?

Correct Answer is C

Explanation

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