A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure.
When the client asks what the stockings do, which of the following responses should the nurse make?
They help keep you warm after your surgery.
They improve your circulation to keep blood from pooling in your legs.
They make it easier for you to do leg exercises after your surgery.
They protect your legs and heels from skin breakdown.
The Correct Answer is B
Choice A rationale
While maintaining normothermia is a critical aspect of perioperative care to prevent surgical site infections and promote proper wound healing, antiembolism stockings are not designed for thermal insulation. Specialized equipment like forced-air warming blankets or warmed intravenous fluids are used for temperature regulation. Attributing warmth to these stockings is scientifically inaccurate because their synthetic material and pressure profile do not provide significant heat retention for the client.
Choice B rationale
Antiembolism stockings provide graduated compression, which is highest at the ankle and decreases as it moves up the leg. This external pressure reduces the diameter of distended veins and increases venous blood flow velocity. By preventing venous stasis and the pooling of blood in the lower extremities, these stockings significantly lower the risk of deep vein thrombosis and subsequent pulmonary embolism, which are common and dangerous complications during and after surgical procedures.
Choice C rationale
These stockings do not facilitate the mechanical process of performing leg exercises such as ankle pumps or knee flexions. While both stockings and exercises aim to prevent venous stasis, the stockings are a passive intervention. Performing leg exercises requires active muscle contraction to engage the skeletal muscle pump. There is no physiological or mechanical evidence to suggest that the presence of compression hosiery makes the physical movement of the limbs easier for the client.
Choice D rationale
While protecting the skin is important, the primary purpose of antiembolism stockings is vascular, not dermatological. In fact, if improperly sized or applied, these stockings can actually increase the risk of skin breakdown, especially over bony prominences like the heels or the bridge of the foot. To prevent pressure injuries on the heels, nurses should use specific pressure-relieving devices or floating techniques rather than relying on compression stockings for skin protection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A glucose level of 75 mg/dL falls within the established normal reference range of 70 to 100 mg/dL for a fasting adult. Stable glycemic control is essential for minimizing the risk of intraoperative fluctuations and supporting effective postoperative wound healing. Because this value is normal, it does not represent an independent risk factor for complications such as delayed healing or infection that would be associated with hyperglycemia or significant hypoglycemia in the preoperative phase.
Choice B rationale
A Body Mass Index (BMI) of 24 is situated within the healthy or normal weight range, which is typically defined as 18.5 to 24.9. Clients within this range generally face fewer risks related to anesthesia administration, surgical access, and postoperative mobility compared to those who are underweight or obese. Since this measurement indicates a healthy physiological state, it is not considered a finding that increases the client's risk for postoperative complications or poor outcomes.
Choice C rationale
A fractured ankle is the likely indication for the surgery itself rather than a systemic risk factor for postoperative complications. While it affects mobility, it does not inherently impair the body's global ability to recover from anesthesia or surgery in the same way a chronic systemic condition does. The surgical team will manage the local trauma, and as long as there are no underlying comorbidities, the fracture does not pose a generalized risk to the client.
Choice D rationale
Obstructive sleep apnea (OSA) is a significant risk factor because it increases the likelihood of perioperative airway obstruction and severe hypoxemia. Anesthesia and postoperative opioids further relax the upper airway muscles and depress the respiratory drive, which can exacerbate OSA. This condition requires careful monitoring, specific positioning, and potentially the use of continuous positive airway pressure (CPAP) during recovery to prevent life-threatening respiratory failure or cardiac strain following the surgical procedure.
Correct Answer is B
Explanation
Choice A rationale
Desmopressin is a synthetic analog of antidiuretic hormone used to treat diabetes insipidus, which is the opposite of SIADH. In SIADH, there is already an excessive secretion of antidiuretic hormone, leading to water retention and dilutional hyponatremia. Administering more antidiuretic hormone would worsen the fluid overload and further decrease the sodium level below the current 123 mEq per L. This would increase the risk of cerebral edema and seizures.
Choice B rationale
Fluid restriction is the primary treatment for SIADH to correct dilutional hyponatremia. The client has a sodium level of 123 mEq per L, which is well below the normal range of 135 to 145 mEq per L. By limiting total fluid intake to 1,000 mL per day or less, the body is forced to eliminate excess water, which helps to gradually increase the serum sodium concentration. This prevents further expansion of the extracellular fluid volume.
Choice C rationale
A diet limited to 2 grams of sodium per day is a low-sodium diet often used for heart failure or hypertension. However, in SIADH, the low sodium level is caused by an excess of water rather than a deficiency of salt. While increasing salt intake might be helpful in some cases of SIADH, restricting sodium to 2 grams would be counterproductive or insufficient. The focus remains on managing the water imbalance rather than strictly limiting salt.
Choice D rationale
An intravenous solution of 0.45 percent sodium chloride is a hypotonic fluid. Administering hypotonic fluids to a patient with SIADH and a sodium level of 123 mEq per L is dangerous. It provides more free water, which would further dilute the serum sodium and worsen the hyponatremia. If intravenous fluids are required for a patient with severe hyponatremia, hypertonic saline like 3 percent sodium chloride is used under very careful monitoring.
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