A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse should identify that which of the following actions by the AP indicates an understanding of the procedure?
Elevates the client's legs before applying the stockings
Instructs the client to dorsiflex their feet while applying the stockings
Massages the client's legs before applying the stockings
Folds the top of the stockings over after applying them
The Correct Answer is A
A. Elevating the client's legs before applying the stockings helps reduce venous stasis by promoting venous return and decreasing edema, which is essential for the effectiveness of the stockings.
B. Dorsiflexion of the feet can also aid in the application but is not as critical as elevation.
C. Massaging the legs is contraindicated as it may dislodge clots if present.
D. Folding the top of the stockings over can create a tourniquet effect and impede blood flow, which is harmful to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Encouraging the client to talk about current events may not be effective, as individuals with Alzheimer's disease may have difficulty following complex conversations or remembering recent events.
B. Giving directions using simple phrases is essential for effective communication with individuals who have Alzheimer's disease. Using clear, concise language helps reduce confusion and frustration and improves the client's ability to understand and follow instructions.
C. Orienting the client to time and place twice per day can be helpful for some individuals with Alzheimer's disease, but the frequency and method of orientation may vary depending on the client's specific needs and preferences. It may not be necessary to orient the client twice per day in all cases.
D. While it's important to provide consistent care to clients with Alzheimer's disease, rotating assistive personnel frequently may lead to confusion and distress for the client. Consistency and familiarity with caregivers can help establish trust and improve the client's sense of security.
Correct Answer is B
Explanation
A. While a cooler foot than in the previous assessment may indicate decreased perfusion, the absence of a palpable pedal pulse is a more significant finding as it suggests compromised arterial blood flow to the foot.
B. The absence of a palpable pedal pulse indicates diminished arterial blood flow to the foot, which is a critical finding following a femoropopliteal bypass graft. It suggests potential complications such as graft occlusion or inadequate blood flow distal to the graft site.
C. Capillary refill time of 5 seconds in the toes may indicate delayed capillary refill, which could be a concern but is not as immediately critical as the absence of a palpable pedal pulse.
D. While pain is an important assessment finding, a pain level of 8 on a scale from 0 to 10 is subjective and does not provide specific information about the client's vascular status. Pain assessment should be considered along with other objective findings.
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