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
Correct. Applying ant embolic stockings while the client is still in bed helps prevent venous stasis.
Incorrect. Turning the stockings inside out is not a correct step in the application process and should be corrected by the nurse.
Correct. Asking the client to point their toes helps ensure proper positioning of the stockings.
Ensuring that creases are on the front of the legs helps prevent pressure points.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. No sounds heard after listening for 3 to 5 minutes would be considered absent bowel sounds.
B. Correct. Hyperactive bowel sounds are louder and more frequent than normal and can indicate increased bowel motility. They can also be present in early bowel obstructions due to increased peristalsis.
C. Incorrect. Soft sounds at a rate of 1/min are within the range of normal bowel sounds.
D. Incorrect. Decreased motility would result in hypoactive bowel sounds, not hyperactive.
Correct Answer is A
Explanation
The correct answer is choice a. Wear shoes with rubber soles.
Choice A rationale:
Wear shoes with rubber soles () - Quiet footwear minimizes noise disruption during sleep hours, promoting a better sleep environment.
Choice B rationale:
Conduct change of shift reports near the clients’ rooms () - Conducting reports near rooms creates noise and disrupts sleep. It’s best done in designated areas away from patients.
Choice C rationale:
Open curtains between clients in semi-private rooms () - Privacy and individual light control are crucial for sleep. Open curtains can disrupt a client’s sleep cycle.
Choice D rationale:
Turn on overhead lights briefly when checking IV lines () - Bright lights suppress melatonin production, a hormone vital for sleep. Using alternative light sources or dimmed lighting minimizes sleep disruption.
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