A nurse is reinforcing teaching with a client regarding application of antiembolic stockings. Which of the following statements by the client indicates an understanding of the teaching?
Knee-high stockings can be rolled down slightly to provide comfort.
I should flex my toes when applying the stockings.
I should reapply the stockings before I get out of bed.
The thigh-high stockings should reach just above the gluteal folds.
The Correct Answer is C
Choice A rationale
Rolling down knee-high stockings can cause constriction and impair blood flow, which is not the intended purpose of these stockings.
Choice B rationale
Flexing the toes when applying the stockings does not necessarily aid in the application or effectiveness of the stockings.
Choice C rationale
Antiembolic stockings should be reapplied before getting out of bed to ensure that they are in place to provide the necessary pressure to the legs when the client is upright. This helps to promote venous return and prevent blood pooling and clot formation.
Choice D rationale
Thigh-high stockings should reach just below the gluteal folds, not above. If they are too high, they can cause constriction and impair blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C.
Choice A rationale
Keeping both arms below the heart level can actually increase the risk of lymphedema development. This position can lead to pooling of lymphatic fluid in the arm, which can exacerbate swelling.
Choice B rationale
Avoiding range-of-motion exercises with the affected arm is not recommended. Regular gentle exercises can help promote lymphatic drainage and prevent lymphedema.
Choice C rationale
Using the client’s left arm (the non-operated arm) to draw blood samples is a recommended practice. This reduces the risk of infection and injury to the right arm, which could potentially trigger or worsen lymphedema.
Choice D rationale
Obtaining blood pressure readings using the client’s right arm (the operated arm) is not recommended. The pressure exerted by the blood pressure cuff can obstruct lymphatic flow and contribute to lymphedema.
Correct Answer is C
Explanation
Choice A rationale
Loosening the screws while cleaning the pin sites is not recommended. The screws are tightened to a specific pressure to ensure the halo vest is secure and provides the necessary immobilization.
Choice B rationale
The nurse should also provide education regarding changing positions at least every 2 hours to reduce pressure injuries.
Choice C rationale
Halo-vests are managed and monitored during spinal outpatient clinics and can be removed during this clinic appointment.
Choice D rationale
The halo ring should never be used to lift or reposition the client because it is directly attached to the skull. Pulling on the ring could cause serious injury or dislocation.
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