Author Question: The nurse is preparing to apply sequential compression devices to a client. In which order should ... (Read 56 times)

ahriuashd · **on:** Jul 23, 2018

The nurse is preparing to apply sequential compression devices to a client. In which order should the nurse apply these devices?

1. Place in the dorsal recumbent or semi-Fowler's position.
2. Place a sleeve under each leg with the opening at the knee.
3. Wrap the sleeve securely around the leg, securing the Velcro tabs.
4. Turn on the control unit and adjust the alarms and pressures as needed.
5. Connect the sleeves to the control unit and adjust the pressure as needed.

Question 2

A client exhibits confusion, decreased capillary refill time, low oxygen saturation readings, and decreased renal output. What NANDA nursing diagnosis problem statement should the nurse choose for this client?

1. Ineffective Tissue Perfusion
2. Decreased Cardiac Output
3. Activity Intolerance
4. Risk for Injury

nicoleclaire22 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1, 2, 3, 5, 4

Rationale 1: When applying sequential compression devices, the nurse should first place the client in the dorsal recumbent or semi-Fowler's position.

Rationale 2: The second step is to place a sleeve under each leg with the opening at the knee.

Rationale 3: The third step is to wrap the sleeve securely around the leg, securing the Velcro tabs.

Rationale 4: The fifth step is to turn on the control unit and adjust the alarms and pressures as needed.

Rationale 5: The fourth step is to connect the sleeves to the control unit and adjust the pressure as needed.

Answer to Question 2

Correct Answer: 1
Rationale 1: Ineffective Tissue Perfusion is the diagnosis assigned when there is a decrease in oxygenation from failure to nourish tissues at the capillary level.
Rationale 2: Decreased Cardiac Output is the diagnosis assigned when there is inadequate blood pumped by the heart to meet the demands of the body.
Rationale 3: Activity Intolerance is the diagnosis assigned when the client does not have the energy for daily activities.
Rationale 4: Risk for Injury is the diagnosis assigned when the client has an increased chance of being injured.