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?
The thigh-high stockings should reach just above the gluteal folds.
I should reapply the stockings before I get out of bed.
I should flex my toes when applying the stockings.
Knee-high stockings can be rolled down slightly to provide comfort.
The Correct Answer is B
Choice A reason: The thigh-high stockings should reach just below the gluteal folds, not above them. If the stockings are too high, they can cause constriction and impair circulation.
Choice B reason: Reapplying the stockings before getting out of bed is an appropriate action. The client should remove the stockings at night and inspect the skin for any signs of irritation or breakdown. The client should also elevate the legs for 15 minutes before putting on the stockings to reduce edema and improve venous return.
Choice C reason: Flexing the toes when applying the stockings is not an appropriate action. The client should point the toes and foot downward when applying the stockings to prevent wrinkles or folds that can cause pressure ulcers.
Choice D reason: Rolling down knee-high stockings slightly to provide comfort is not an appropriate action. The client should avoid rolling or folding the stockings as this can create a tourniquet effect and impair blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: This is correct because offering artificial saliva frequently can help moisten the mouth and improve the taste of food. Radiation therapy can cause dry mouth and altered taste sensation.
Choice B: This is incorrect because providing three large meals daily can be overwhelming and unappetizing for the client. The nurse should provide small, frequent meals that are high in protein and calories.
Choice C: This is incorrect because adding honey to sweeten fruit smoothies can irritate the throat and increase the risk of infection. The nurse should avoid foods that are acidic, spicy, or sticky.
Choice D: This is incorrect because heating food before serving can enhance the unpleasant taste and smell of food. The nurse should serve food cold or at room temperature.
Correct Answer is B
Explanation
Choice A reason: Applying restraints to the client is not an appropriate action, as it can cause injury or suffocation to the client during a seizure. The nurse should protect the client from harm by removing any nearby objects and padding the side rails.
Choice B reason: Administering an IV bolus of lorazepam is an appropriate action, as lorazepam is an anticonvulsant drug that can stop or shorten the duration of a seizure by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) in the brain.
Choice C reason: Placing the client in the prone position is not an appropriate action, as it can obstruct the airway and cause respiratory distress or aspiration during a seizure. The nurse should place the client in the side-lying position to facilitate drainage of oral secretions and prevent tongue biting.
Choice D reason: Inserting a tongue blade into the client's mouth is not an appropriate action, as it can cause oral trauma or choking during a seizure. The nurse should never force anything into the client's mouth during a seizure and should allow them to breathe spontaneously.
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