A nurse is supervising an assistive personnel (AP. who is applying anti-embolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?
Applying the stockings before the client gets out of bed
Turning the stockings inside out before applying them
Asking the client to point their toes before applying the stockings
Ensuring that creases in the stockings are on the front of the client's legs
The Correct Answer is D
The nurse must intervene if the AP leaves creases or folds in the stockings because wrinkles and creases create uneven pressure points that can restrict blood flow and irritate the skin. Anti-embolic stockings are designed to provide smooth, graduated compression to promote venous return; any bunching or folding defeats this purpose and increases the risk of skin breakdown or thrombus formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Insert an oral airway into the client's mouth.Inserting anything into the client’s mouth during a seizure is contraindicated due to the risk of oral injury, aspiration, or causing airway obstruction.
B. Lower the side rails of the bed when the seizure begins.Lowering the side rails is inappropriate and increases the risk of the client falling out of bed and sustaining an injury. Instead, the nurse should ensure padded side rails are in place or protect the client by cushioning their head and limbs if side rails are not padded.
C. Measure the duration of the seizure.It is critical to measure the duration of a seizure to provide accurate information to the healthcare team. The duration helps determine the severity of the seizure and the need for medical interventions, such as administering medications to stop prolonged seizures (status epilepticus).
D. Restrain the client's arms and legs to prevent injury.Restraint during a seizure is inappropriate and can cause musculoskeletal injuries. The nurse should allow the seizure to run its course while ensuring the client’s safety.
Correct Answer is A
Explanation
A. Correct. To ensure the information is accessible to a wide audience, it should be written at an 8th-grade reading level, which is suitable for the general population.
B. Using basic, one-syllable words is a good approach, but the reading level should also be considered.
C. Presenting information from complex to simple might be helpful, but starting with simpler concepts is more effective for understanding.
D. While font size is important for readability, the reading level of the content is more critical for comprehension.
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