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Difficulty: MediumBasic Care and Comfort

A nurse is caring for an older adult client who is 1 day post-operative following an abdominal surgery. The provider has prescribed knee-high antiembolism stockings to promote venous return. Which of the following actions should the nurse take?

  1. A
    Delegate the initial assessment of the client's pedal pulses, capillary refill, and skin integrity to an unlicensed assistive personnel (UAP).
  2. B
    Document the client's new onset of severe confusion and restlessness as an expected normal change associated with the aging process.
  3. Measure the circumference of the client's calf at its widest point and the leg length from the heel to the popliteal fold to determine the correct size.Answer
  4. D
    Place a rolled towel or pillow directly under the client's knees to support the lower extremities and provide comfort after applying the stockings.

Answer

The nurse should measure the circumference of the client's calf at its widest point and the leg length from the heel to the popliteal fold to determine the correct stocking size.
To ensure antiembolism stockings provide the correct amount of graduated compression without impeding circulation, the nurse must accurately measure the client's legs. For knee-high stockings, this involves measuring the calf circumference at the widest point and the length from the bottom of the heel to the popliteal fold. Properly sized stockings promote venous return and prevent complications like deep vein thrombosis.

Step-by-Step Solution

1
Identify the client's risk factors and the provider's prescription.
The client is post-operative and requires knee-high antiembolism stockings to prevent deep vein thrombosis (DVT).
Ensures the correct intervention is being prepared based on the client's specific clinical needs.
2
Determine the necessary preparation steps for applying the stockings safely.
Accurate measurement of the client's legs is required before application.
Stockings that are too tight can restrict arterial blood flow, while those that are too loose will not provide adequate venous compression.
3
Evaluate the remaining options for safety and adherence to the nursing scope of practice.
Delegating initial assessments, ignoring acute confusion, and placing pressure on the popliteal space are all unsafe or incorrect actions.
Eliminating contraindicated interventions isolates the correct, evidence-based nursing action.

Key Concept

Basic Care and Comfort: Antiembolism Stocking Application and Safety
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Topics

Basic Care and Comfort

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