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Zorluk: ZorBasic Care and Comfort

A registered nurse is preparing to apply knee-length anti-embolism stockings to a client who is on strict bed rest. Place the following nursing actions in the correct order from first to last. (All steps are required.)

  1. 1Measure the client's calf circumference and leg length to determine the appropriate stocking size.
  2. 2Place the client in a supine position and elevate the legs for 15 to 30 minutes.
  3. 3Insert a hand into the stocking, grasp the heel pocket, and turn the stocking inside out.
  4. 4Slide the foot portion of the stocking smoothly over the client's toes and heel.
  5. 5Pull the remaining fabric up over the calf and smooth out any wrinkles.

Cevap

The correct sequence begins with measuring the client's legs to ensure proper sizing, followed immediately by elevating the legs to promote venous drainage. The nurse then prepares the stocking by turning it inside out, applies it over the foot and heel, and finally smooths it up the calf to prevent wrinkles.
The correct sequence ensures that stockings provide optimal therapeutic benefit. Proper sizing and pre-elevation of the legs prevent the trapping of venous blood. The specific inside-out application technique minimizes friction and prevents skin shearing during application, while smoothing the fabric prevents dangerous tourniquet effects.

Adım Adım Çözüm

1
Measure the client's calf circumference and leg length to determine the appropriate stocking size.
Secures the correct fit for the client's specific anatomy.
Accurate sizing is required prior to application to ensure therapeutic compression without restricting arterial flow.
2
Place the client in a supine position and elevate the legs for 15 to 30 minutes.
Empties engorged superficial veins.
Applying compression stockings while blood is pooled in the lower extremities traps venous blood and can promote, rather than prevent, thrombus formation.
3
Insert a hand into the stocking, grasp the heel pocket, and turn the stocking inside out.
Inverts the stocking down to the heel section.
This specific technique allows the stocking to be rolled smoothly onto the leg rather than bunched up, minimizing skin shearing.
4
Slide the foot portion of the stocking smoothly over the client's toes and heel.
Anchors the stocking correctly on the distal extremity.
Aligning the heel patch exactly over the client's heel prevents localized friction and pressure ulcers.
5
Pull the remaining fabric up over the calf and smooth out any wrinkles.
Completes the application process with uniform compression.
Wrinkles, folds, or rolled top edges act as a tourniquet, cutting off venous return and increasing the risk of deep vein thrombosis.

Anahtar Kavram

Immobility Interventions: Anti-embolism Stockings Application
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