Author Question: A client is prescribed antiembolic stockings. How should the nurse assess the skin on the client's ... (Read 64 times)

crazycityslicker · **on:** Jul 23, 2018

A client is prescribed antiembolic stockings. How should the nurse assess the skin on the client's legs?

1. Defer the assessment because the stockings are in place.
2. Remove the stockings for this assessment.
3. Review the morning assessment, but don't repeat it unless a problem occurs.
4. Assess the skin when the client removes the stockings at bedtime.

Question 2

On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that something popped in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken

1. Notify the client's surgeon.
2. Cover the area with a large saline-soaked dressing.
3. Position the client in bed with knees bent.
4. Pack the wound with nonadherent gauze.

rleezy04 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 2
Rationale 1: The stockings are worn day and night, so the client will not remove them for sleep.
Rationale 2: The stockings should be removed to do this assessment.
Rationale 3: The nurse is responsible for assessing the skin under the stockings and should not assume that the morning nurse's assessment is still accurate 12 hours later.
Rationale 4: The stockings are worn day and night, so the client will not remove them for sleep.

Answer to Question 2

Correct Answer: 2
Rationale 1: Although notifying the surgeon is important, it is not the nurse's first action.
Rationale 2: Evisceration occurs when an abdominal wound opens and there is protrusion of the internal viscera through the incision. The nurse's first action should be to cover the area with a large saline-soaked dressing to keep the viscera moist.
Rationale 3: Although positioning the client is important, it is not the nurse's first action.
Rationale 4: Nothing should be packed into this wound.