Answer to Question 1
Which finding would the nurse need to report to the health care provider as soon as possible?
1. After beginning sequential compression device application, the client's toes are found to be cool to the touch and mottled, with absent pedal pulses.
2. After applying antiemboli stockings, the client says the stockings feel snug.
3. When applying antiemboli stockings, the nurse finds they are too small for this client.
4. The client asks the nurse to wait to apply the antiembolism stockings until after breakfast.
Correct Answer: 1
If the client's toes become cool to the touch and mottled in appearance, and the pedal pulse disappears, the nurse should remove the compression device and notify the health care provider immediately. If the toes return to a normal appearance after discontinuation of the device, the health care provider should be notified, perhaps not immediately but as soon as possible, to explain what occurred when the device was turned on. The stockings are supposed to be snug, so this would be a normal finding. If the stockings are too small, the nurse would return those stockings and order a larger size. Whenever possible, try to apply the stockings before the client gets out of bed, but waiting until after breakfast would be acceptable, and certainly would not require health care provider notification.
Answer to Question 2
Correct Answer: 4
There would be no need to document when the stockings are laundered. All of the other data should be documented.
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