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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Answer: D. "Clean the prosthesis using a damp, soapy cloth."

Rationale:

A. "Keep initial pressure dressing in place for 1 week after surgery":
The pressure dressing is typically changed more frequently to monitor the incision site for signs of infection and to ensure appropriate healing. Keeping it in place for a week without monitoring could increase the risk of infection and complications.

B. "Leave the prosthesis in place when going to bed":
It is generally recommended to remove the prosthesis at night to allow the residual limb to rest and prevent skin irritation or pressure sores. Leaving it on overnight can lead to unnecessary strain on the limb.

C. "Avoid extension of the hips when lying down":
Clients should actually avoid prolonged hip flexion, not extension, as it can lead to hip contractures. Instead, they should try to lie prone periodically to stretch the hip and reduce the risk of contracture formation.

D. "Clean the prosthesis using a damp, soapy cloth":
Using a damp, soapy cloth to clean the prosthesis helps maintain hygiene and prevents skin irritation. It's important to keep the prosthesis clean to avoid any buildup of bacteria or dirt, which can affect both the device and the residual limb’s health.

A. Serve meals with plastic utensils. B. Assign another client to accompany the client to therapy sessions. C. Assign the client to a private room. D. Check on the client every 4 hr.

Correct Answer is A

Explanation

- Rationale for A: Serving meals with plastic utensils is a safety measure to prevent self-harm. Metal utensils can be used as weapons, so plastic is a safer alternative. This action reflects the priority of maintaining a safe environment for the client.
- Rationale for B: Assigning another client to accompany the client to therapy sessions is not advisable. It may violate privacy and confidentiality, and it is not the responsibility of other clients to monitor safety.
- Rationale for C: Assigning the client to a private room could be beneficial for monitoring purposes, but it does not directly prevent self-harm. It is also important to consider that constant observation is necessary regardless of room assignment.
- Rationale for D: Checking on the client every 4 hours is not sufficient for a client who is at high risk for suicide. More frequent monitoring is needed to ensure the client's safety and to intervene promptly if necessary.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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