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
The action by the AP that indicates an understanding of the procedure is elevating the client's legs before applying the stockings. Elevating the legs can help reduce swelling and make it easier to apply the stockings.
Option b is incorrect because instructing the client to dorsiflex their feet while applying the stockings may not be necessary.
Option c is incorrect because massaging the client's legs before applying the stockings may not be necessary or appropriate.
Option d is incorrect because folding the top of the stockings over after applying them may not be necessary or appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When taking allopurinol, a medication commonly used to treat gout and prevent kidney stones, the nurse should instruct the client to monitor and report the manifestation of a skin rash with fever. Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening condition that can occur as a rare side effect of allopurinol. It is characterized by a widespread rash, often with fever, and can progress to involve the mucous membranes (e.g., mouth, eyes) and cause severe complications.
The other manifestations mentioned, such as diplopia (double vision), tinnitus with ear pain, and hyperreflexia (exaggerated reflexes), are not typically associated with Stevens-Johnson syndrome and should not be directly attributed to this condition. However, it's important for the client to report any unusual or severe symptoms to their healthcare provider for further evaluation and appropriate management.
Correct Answer is D
Explanation
ESR is a laboratory test that measures the rate at which red blood cells settle in a vertical tube of blood over a specific period of time. An elevated ESR is a nonspecific indicator of inflammation in the body, including infections. In the presence of an infection, the body releases certain substances that can increase the rate at which red blood cells settle, leading to an elevated ESR.
Decreased platelet count is not typically associated with infection. Low platelet count, known as thrombocytopenia, can be caused by various factors such as certain medications, autoimmune disorders, or bone marrow disorders. Infection may cause other changes in blood counts, but decreased platelets are not a direct indicator of infection.
Decreased hemoglobin levels, known as anemia, can be caused by various factors such as nutritional deficiencies, chronic diseases, or blood loss. While some infections can lead to anemia indirectly, decreased hemoglobin is not a specific indicator of infection.
Increased iron levels, known as hyperferritinemia, can occur in various conditions, including infections, but it is not a direct indicator of infection. It is important to assess the overall clinical picture and other laboratory findings to determine the cause of increased iron levels.
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