A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

"They'll protect your legs and heels from skin breakdown."

"They'll make it easier for you to do leg exercises after your surgery."

They'll improve your circulation to keep blood from pooling in your legs."

"They'll help keep you warm immediately after your surgery."

Answer and Explanation

The Correct Answer is C

A. “They’ll protect your legs and heels from skin breakdown.”: While antiembolism stockings can provide some degree of protection against skin breakdown due to their snug fit, this is not their primary purpose. Their main function is to improve circulation and prevent blood clots, not to protect the skin.

B. “They’ll make it easier for you to do leg exercises after your surgery.”: Antiembolism stockings do not directly facilitate leg exercises. While they can help improve circulation which might indirectly aid in recovery, their primary purpose is to prevent the formation of blood clots in the lower extremities.

C. “They’ll improve your circulation to keep blood from pooling in your legs.”: This is correct. Antiembolism stockings, also known as compression stockings, are designed to apply pressure to your lower legs, helping to maintain blood flow and reduce discomfort and swelling. They can help prevent deep vein thrombosis (DVT), a type of blood clot that’s most common in the deep veins of your legs.

D. “They’ll help keep you warm immediately after your surgery.”: While antiembolism stockings might provide some warmth due to their material, this is not their primary function. Their main purpose is to improve circulation in the legs and prevent blood clots.

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Correct Answer is B

Explanation

A. "This medication will help maintain a normal heart rhythm":

Warfarin is not typically used to maintain a normal heart rhythm in atrial fibrillation. It is primarily used for stroke prevention by anticoagulation.

B. "Warfarin helps prevent strokes in clients who have atrial fibrillation":

This statement is accurate. Warfarin is an anticoagulant medication that is commonly prescribed for clients with atrial fibrillation to reduce the risk of stroke by preventing blood clots from forming in the heart and traveling to the brain.

C. "Warfarin dissolves clots in the bloodstream":

Warfarin does not directly dissolve clots in the bloodstream. It works by inhibiting the production of clotting factors in the liver, thereby preventing the formation of new clots and reducing the risk of clot-related complications such as stroke.

D. "This medication slows the response of the ventricles to the fast atrial impulses":

This statement refers more to medications used for rate control in atrial fibrillation rather than warfarin. Warfarin does not directly affect the heart rate or the response of the ventricles to atrial impulses.

A. An adolescent who asks to stay in the hospital because he likes the room B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy C. A school-age child who cries when the nurse is giving him an injection D. A preschooler who has a BMI indicating obesity

Correct Answer is A

Explanation

Answer: A. An adolescent who asks to stay in the hospital because he likes the room

Rationale:

A) An adolescent who asks to stay in the hospital because he likes the room: This finding may indicate that the adolescent is experiencing abuse or neglect at home. A desire to remain in the hospital could suggest that the child views it as a safe space compared to their home environment, warranting further assessment for possible abuse.

B) A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy: Bruising on the shins is common in toddlers due to normal exploratory behavior and frequent falls. The parent's explanation aligns with developmental norms, making this finding less indicative of abuse.

C) A school-age child who cries when the nurse is giving him an injection: Crying during injections is a typical reaction for school-age children and does not suggest abuse. Emotional responses to medical procedures are age-appropriate and expected.

D) A preschooler who has a BMI indicating obesity: While obesity in children may raise concerns about diet and lifestyle, it is not inherently indicative of abuse. Further evaluation may be needed for nutritional and health interventions but does not typically suggest maltreatment.

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A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

Nursing Test Bank

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Correct Answer is A

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