A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Ensuring that creases in the stockings are on the front of the client's legs

Applying the stockings before the client gets out of bed

Asking the client to point their toes before applying the stockings

Turning the stockings inside out before applying them

Answer and Explanation

The Correct Answer is A

Choice A rationale:

This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.

Choice B rationale:

Applying the stockings before the client gets out of bed is correct. Antiembolic stockings should be applied before the client gets out of bed to prevent blood from pooling in the legs, which can help reduce the risk of deep vein thrombosis (DVT).

Choice C rationale:

Asking the client to point their toes before applying the stockings is a correct action. This helps in the proper fitting of the stockings and ensures they are applied smoothly without causing discomfort.

Choice D rationale:

Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.

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Correct Answer is A

Explanation

A. Neonatal Infant Pain Scale (NIPS): The NIPS is a widely used and validated pain assessment tool specifically designed for newborns, including full-term infants like the 38-week gestation newborn in this case. It evaluates behavioral indicators such as facial expressions, crying, arm and leg movement, and physiological indicators like breathing patterns.

B. FACES pain rating scaleis designed for older children who can self-report pain by selecting a facial expression corresponding to their level of discomfort. It is not suitable for newborns who cannot self-report their pain.

C. Premature Infant Pain Profile (PIPP):The PIPP is specifically designed for preterm infants (less than 37 weeks of gestation) and assesses pain based on behavioral and physiological indicators.

D. Visual Analog Scale (VAS): The VAS requires a client to self-report their pain by indicating a point along a continuum, which is not appropriate for newborns.

A. Assign the client to a negative pressure airflow room. B. Have visitors remain at least 0.91 m (3 feet) away from the client. C. Initiate contact precautions for the client. D. Administer aspirin if the client develops a fever.

Correct Answer is ["A","C"]

Explanation

Varicella zoster is highly contagious, and airborne precautions should be implemented. Assigning the client to a negative pressure airflow room helps prevent the spread of the virus to others by containing and filtering the air within the room.

In addition to airborne precautions, contact precautions should also be implemented. This includes using gloves and gowns when providing care to the client to minimize direct contact with infectious materials.

The other options listed are not appropriate interventions for a client with varicella zoster: While it is important to minimize close contact with an infectious client, varicella zoster is

primarily transmitted through airborne droplets. Visitors should follow the appropriate precautions, such as wearing masks and adhering to hand hygiene, rather than just maintaining a certain distance.

Aspirin should not be given to clients with varicella zoster, especially children, due to the risk of developing Reye's syndrome. Reye's syndrome is a rare but serious condition that can cause swelling in the liver and brain. Acetaminophen (paracetamol) is typically recommended for managing fever in clients with varicella zoster.

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A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is ["A","C"]

Explanation

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