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 B
Explanation
A. Incorrect. Justice refers to fairness and equal treatment for all clients. It is not demonstrated in this scenario.
B. Correct. Fidelity, also known as "faithfulness" or "loyalty," refers to the nurse's commitment to keeping promises and maintaining trust with the client. By walking with the client as promised, the nurse is demonstrating fidelity.
C. Incorrect. Autonomy refers to the client's right to make decisions about their own care and treatment. While the nurse is respecting the client's autonomy by addressing their anxiety, the ethical principle being demonstrated here is fidelity.
D. Incorrect. Nonmaleficence refers to the duty to do no harm. While the nurse is indeed trying to prevent harm (anxiety. for the client, the ethical principle being demonstrated in this scenario is fidelity.
Correct Answer is A
Explanation
A. Correct. The American Academy of Pediatrics (AAP. recommends keeping infants rear-facing in their car seats until at least the age of 2, or until they reach the maximum weight and height limits recommended by the car seat manufacturer. This is to ensure optimal safety for the child's head, neck, and spine.
B. Incorrect. The retainer clip should be positioned at armpit level to ensure proper fit of the harness straps.
C. Incorrect. While it's important to ensure the proper recline angle of the car seat, the specific angle may vary based on the car seat manufacturer's instructions.
D. Incorrect. It is not safe to enable the airbag when a baby is in the front seat, as airbags can be dangerous for infants due to their size and vulnerability.
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