The nurse understands that sequential compression devices and compression stockings are used for which of the following?

Protect the muscles of the lower extremities from atrophy.

Keep the blood from pooling in lower extremities to avoid clots.

Keep the patient from getting sores on the skin.

Keep the patient’s joints in working order.

Answer and Explanation

The Correct Answer is B

A. Protect the muscles of the lower extremities from atrophy:

This statement is not the primary purpose of sequential compression devices (SCDs) and compression stockings. While these devices can help maintain muscle tone by promoting blood circulation, their primary function is to prevent blood pooling and reduce the risk of deep vein thrombosis (DVT).

B. Keep the blood from pooling in lower extremities to avoid clots:

This is the correct purpose of sequential compression devices and compression stockings. They are designed to promote venous return and prevent blood from pooling in the lower extremities, thereby reducing the risk of blood clots, especially in individuals at risk for deep vein thrombosis (DVT).

C. Keep the patient from getting sores on the skin:

Preventing sores on the skin is not the primary purpose of these devices. While improved circulation may contribute to skin health, preventing skin sores is not the primary therapeutic goal of SCDs and compression stockings.

D. Keep the patient’s joints in working order:

Maintaining joint function is not the primary purpose of sequential compression devices and compression stockings. These devices primarily focus on promoting venous circulation and preventing complications related to blood pooling and clot formation.

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Correct Answer is A

Explanation

A. Perform oral hygiene at least every 2 hours:

Regular oral care is essential to maintain oral health, prevent infections, and provide comfort. When a client is NPO, and especially if they are weak or drowsy, the nurse should perform oral care at least every 2 hours to keep the oral cavity moist, reduce the risk of infection, and provide comfort.

B. Client must be supine with the head of the bed below 30 degrees:

Keeping the head of the bed elevated to at least 30 degrees is important for preventing aspiration and promoting respiratory function. This position is not specific to oral care but is a general guideline for managing clients at risk for aspiration.

C. Use alcohol-based mouth rinse with oral swab:

Alcohol-based mouth rinses can be drying and may not be suitable for a client who is NPO, as they might contribute to further dryness of the oral mucosa. Non-alcohol-based mouth rinses or moistened oral swabs are often preferred.

D. Assist the client with oral care by brushing their teeth twice daily:

While regular oral care is important, the frequency of twice daily brushing may not be sufficient for a weak, drowsy client, especially if they are NPO. Oral care should be performed more frequently to maintain oral hygiene.

A. 20 bpm B. 10 bpm C. 09 bpm D. 18 bpm

Correct Answer is B

Explanation

A. 20 bpm: This is twice the calculated rate, so it's significantly higher than observed.

B. 10 bpm: This matches closely with the calculated rate of approximately 10.23 breaths per minute.

The scenario describes the nurse counting the client's breaths starting from when the second hand of the clock was at 12 and ending just past 5, and the client completed 9 breaths during this time frame.

Counting Period:

From just past 12 to just past 5 on the clock, the time span is approximately 53 seconds.

Number of Breaths:

The client completed 9 breaths within this time frame.

Now, to calculate the respiratory rate:

Respiratory rate = (Number of breaths / Time in minutes)

Respiratory rate = (9 breaths / 0.88 minutes) (53 seconds converted to minutes)

After calculation, the respiratory rate is approximately 10.23 breaths per minute.

C. 09 bpm: This is a lower value than observed and doesn't align with the counted breaths.

D. 18 bpm: This is close to double the observed rate, which doesn't match with the counted breaths within the time frame.

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The nurse understands that sequential compression devices and compression stockings are used for which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing oral care for a client who is weak, drowsy, and unable to take anything by mouth (NPO). Which of the following would the nurse implement when performing appropriate oral care for this client?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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