- A 62-year-old client is 2 days post–knee replacement surgery and is using compression stockings. The nurse documents calf circumferences as 39 cm (nonoperative) and 39 cm (operative), no warmth, no redness, and trace edema; the client ambulates with assistance twice per shift. Which observation indicates the compression device is working effectively?
Answer: Leg swelling remains minimal and calf circumferences stay equal without new warmth or redness
This question tests understanding of DVT prevention and use of compression devices. The priority concern is evaluating outcomes of compression stockings in preventing DVT signs like swelling or asymmetry postoperatively. Observing minimal leg swelling with equal calf circumferences and no warmth or redness indicates effective compression by maintaining venous flow and reducing stasis. Decreasing pain scores relate to analgesia; improved appetite is unrelated; removing stockings most of the day diminishes protection. The decision-making principle in compression therapy is to use symmetric measurements and absence of symptoms as indicators of success. This confirms ongoing DVT prevention. A transferable strategy is to track trends in edema and circumference measurements daily, correlating with ambulation to ensure device effectiveness over time.
- A 65-year-old hospitalized client is on bed rest after a stroke and has SCDs in place. Assessment shows new redness and tenderness along the back of the left calf; left calf circumference is 37 cm and right is 34 cm. What is the PRIORITY nursing action for this client?
Answer: Stop using the SCD on the affected leg and report the findings to the RN promptly
This question tests understanding of DVT prevention and use of compression devices. The priority concern is new unilateral calf redness, tenderness, and enlargement, suggesting possible DVT, requiring immediate cessation of compression on the affected leg to avoid clot dislodgement. Stopping SCD use on the affected leg and reporting promptly allows for safe evaluation and management. Encouraging ankle circles or massaging risks embolization; applying warmth could worsen inflammation. The decision-making principle in compression therapy is to discontinue use on symptomatic legs and escalate for suspected thrombosis. This prevents complications like pulmonary embolism. A transferable strategy is to halt compression and notify providers upon detecting unilateral symptoms, followed by monitoring vital signs to ensure timely DVT intervention.
- A 67-year-old client is hospitalized and bedridden after a stroke with right-sided weakness. The client is using SCDs for DVT prevention; the nurse measures calf circumference as 34 cm (left) and 38 cm (right) with new right calf warmth and 1+ edema. The nurse should REPORT which finding to the RN?
Answer: Right calf circumference is 4 cm larger than the left with warmth and new swelling
This question tests understanding of DVT prevention and use of compression devices. The priority concern is recognizing signs of possible DVT, such as unilateral swelling, warmth, and increased calf circumference, which require immediate reporting to prevent complications like pulmonary embolism. The finding of the right calf circumference being 4 cm larger than the left with warmth and new swelling should be reported as it indicates a potential thrombus formation despite SCD use. Preferring a cooler room is unrelated to DVT; faint indentations from SCDs are normal and temporary; requesting to keep SCDs on while sitting may be appropriate but is not a critical finding to report. The decision-making principle in compression therapy is to monitor for asymmetric leg changes that suggest DVT, even with preventive measures in place. Prompt reporting allows for timely diagnostic evaluation and intervention. A transferable strategy is to measure and compare bilateral calf circumferences regularly and report any discrepancies greater than 2-3 cm to ensure early detection of DVT risks.
- A 77-year-old long-term care resident with limited mobility is using SCDs for DVT prevention. The nurse assesses that the sleeves inflate, but the resident's legs are dangling over the side of the bed during inflation; calf circumferences are equal with mild edema. Which action is MOST important for ensuring the effectiveness of the compression device?
Answer: Assist the resident to keep legs supported in bed or in a chair with legs elevated as appropriate while SCDs are in use
Compression sleeves promote venous return during inflation, but they cannot overcome the effect of gravity if the legs are dangling. The priority is to position the resident with legs supported in bed or elevated in a chair while the sleeves are in use, because that keeps the compressed veins in a position that assists outflow. Applying powder under the sleeves addresses moisture and skin comfort, not the effectiveness of compression, and can interfere with sleeve-skin contact. Removing the sleeves for a short period while awake interrupts the prescribed prophylaxis and does not correct the positioning problem. Increasing inflation time or adjusting the pressure setting is outside the nurse's independent role, does not address the dangling legs, and could compromise circulation or device settings. The equal calf circumferences with mild edema should not distract from the positional hazard; the nurse's action must target venous stasis caused by the dependent position.
- A 66-year-old client is hospitalized and immobile after a stroke; sequential compression devices (SCDs) are ordered. The nurse finds the SCD sleeves applied over knee-high anti-embolism stockings, and the client has redness at the back of the knees; calf circumferences are equal at 32 cm bilaterally and there is 1+ ankle edema. What is the PRIORITY nursing action for this client?
Answer: Remove the devices, assess skin and circulation, then reapply the SCDs correctly per facility policy and report the skin redness to the RN
The priority is to remove the improper layering that is causing pressure at the back of the knees. Leaving both the SCD sleeves and the anti-embolism stockings in place would continue that harmful pressure and delay needed intervention. Removing only the SCDs and keeping the stockings fails to provide adequate DVT prophylaxis and omits assessment and reporting. Requesting a topical antibiotic treats a symptom rather than the mechanical cause and is not appropriate for pressure-related redness. The correct action is to remove the devices, assess skin and circulation, reapply the SCDs correctly per facility policy, and report the redness to the RN—this resolves the pressure issue and maintains safe compression.
- A 70-year-old home health client is recovering 1 week after hip surgery and has risk factors for DVT including age and decreased mobility. The caregiver reports the compression stockings are worn "most of the day"; the nurse notes mild ankle edema and that the stockings are rolled down at the top. Which action is MOST important for ensuring the effectiveness of the compression device?
Answer: Teach the caregiver to avoid rolling the stockings down and to smooth them flat to prevent a tight band
This question tests understanding of DVT prevention and use of compression devices. The priority concern is incorrect application of compression stockings, such as rolling down, which creates a tourniquet effect and impairs circulation in a postoperative client. Teaching the caregiver to avoid rolling and smooth them flat prevents tight bands, ensuring optimal graduated compression to enhance venous return. Applying only when swelling is present is inconsistent; doubling stockings increases pressure unevenly; requesting pain medication does not address application errors. The decision-making principle in compression therapy is to educate on proper donning techniques to avoid constriction and maintain even pressure. This promotes effective DVT prevention without causing harm. A transferable strategy is to demonstrate and have caregivers return-demonstrate stocking application, reassessing fit regularly to ensure ongoing effectiveness.
- A 59-year-old home health client is recovering after hip surgery and has decreased mobility. The caregiver reports the compression stockings are difficult to put on, so they are applied after the client has been up walking for an hour; the nurse notes 2+ ankle edema. Which action is MOST important for ensuring the effectiveness of the compression device?
Answer: Teach to apply the stockings in the morning before the client gets out of bed when swelling is lowest
This question tests understanding of DVT prevention and use of compression devices. The priority concern is timing of compression stocking application, as applying after activity allows swelling to occur, reducing effectiveness. Teaching to apply in the morning before getting out of bed when swelling is lowest optimizes use by preventing edema buildup and maintaining graduated compression. Applying only on non-walking days is inconsistent; cutting slits compromises integrity; increasing compression without measurement risks injury. The decision-making principle in compression therapy is to time application to minimize swelling for best fit and efficacy. This enhances DVT prevention in recovering clients. A transferable strategy is to educate on daily morning application routines and assess edema levels pre- and post-application to ensure device effectiveness.
- A 69-year-old client is hospitalized after a stroke and is mostly bedridden. SCDs are ordered; the nurse notes the client complains of numbness in the toes while the sleeves are inflated, and the toes appear dusky. The nurse should REPORT which finding to the RN?
Answer: Numbness in toes with dusky color while SCDs are inflating
This question tests understanding of DVT prevention and use of compression devices. The priority concern is numbness and dusky toes during SCD inflation, indicating potential circulatory compromise from excessive pressure or poor fit. Reporting numbness in toes with dusky color while SCDs are inflating alerts the RN for adjustment or evaluation to prevent injury. Requesting water is unrelated; daily bowel movements are normal; pump sounds indicate function but not patient tolerance. The decision-making principle in compression therapy is to monitor for sensory and color changes during use and report promptly. This ensures safe application in bedridden clients. A transferable strategy is to assess toe color, sensation, and warmth during inflation cycles every 2-4 hours, reporting issues to sustain effective and safe use.
- A 75-year-old hospitalized client is on bed rest after a stroke and has SCDs ordered. The nurse finds one sleeve is not inflating; the tubing is kinked under the bed rail, and the client has 1+ bilateral lower-leg edema with equal calf circumferences. Which action is MOST important for ensuring the effectiveness of the compression device?
Answer: Unkink the tubing, ensure connections are secure, and verify the sleeve inflates and deflates properly
This question tests understanding of DVT prevention and use of compression devices. The priority concern is a non-inflating SCD sleeve due to kinked tubing, which disrupts unilateral compression and increases DVT risk. Unkinking the tubing, securing connections, and verifying inflation/deflation restores balanced function for venous return. Removing and reapplying later delays therapy; placing a pillow behind knees promotes stasis; ordering a sedative is inappropriate. The decision-making principle in compression therapy is to immediately troubleshoot and correct mechanical issues for continuous operation. This is essential in bedridden clients. A transferable strategy is to trace tubing and connections during routine checks, addressing kinks promptly to ensure uninterrupted device effectiveness.
- A 61-year-old client is 1 day post–knee replacement surgery and is using compression stockings. The nurse finds the client sitting in a chair with stockings on; the client reports calf pain rated 6/10 on the operative side, and the calf circumference is 2.5 cm larger than the other leg. The nurse should REPORT which finding to the RN?
Answer: Client reports new unilateral calf pain with increased calf circumference compared to the other leg
This question tests understanding of DVT prevention and use of compression devices. The priority concern is detecting early signs of DVT, such as new unilateral calf pain and increased circumference, which necessitate reporting to prevent escalation. Reporting the client's new unilateral calf pain with increased circumference compared to the other leg alerts the RN for further assessment and intervention. Requesting an extra blanket is unrelated; clean, wrinkle-free stockings are expected; fatigue after therapy is normal and not critical. The decision-making principle in compression therapy is to prioritize reporting symptoms suggestive of thrombosis over routine observations. This ensures timely management in postoperative clients. A transferable strategy is to assess and compare pain levels and calf measurements bilaterally during each shift, reporting variances to maintain effective monitoring for DVT.
- A 80-year-old long-term care resident with limited mobility is using SCDs for DVT prevention. The nurse assesses intact skin, equal calf circumferences, and no redness; the resident's SCD sleeves are removed for a scheduled skin check and hygiene. Which action is MOST important for ensuring the effectiveness of the compression device?
Answer: Reapply the SCD sleeves promptly after care and ensure the device cycles correctly while the resident is in bed
This question tests understanding of DVT prevention and use of compression devices. The priority concern is minimizing interruptions in SCD therapy during routine care to sustain DVT prevention in a limited-mobility resident. Reapplying the SCD sleeves promptly after care and ensuring correct cycling optimizes continuous compression while in bed. Keeping off for the shift reduces protection; applying only if swelling develops is reactive; discontinuing ignores ongoing risk. The decision-making principle in compression therapy is to resume use immediately after brief removals for hygiene or checks. This maintains prophylactic benefits. A transferable strategy is to time reapplication within 30 minutes post-removal and verify function to ensure consistent effectiveness in long-term care.
- A 63-year-old client is hospitalized after an ischemic stroke and is on bed rest with minimal leg movement. SCDs are in use; the nurse notes the client's heels are resting on the bed, and the SCD sleeves are bunched behind the knees. Which action is MOST important for ensuring the effectiveness of the compression device?
Answer: Reposition and smooth the sleeves so they are not wrinkled or bunched and ensure proper fit
This question tests understanding of DVT prevention and use of compression devices. The priority concern is improper positioning of SCD sleeves, which can impair compression and venous return in a bedridden client post-stroke. Repositioning and smoothing the sleeves to eliminate wrinkles and ensure proper fit optimizes use by allowing even pressure distribution and preventing pressure points or reduced efficacy. Increasing pump pressure risks injury; using a heating pad is contraindicated with SCDs; applying only at night limits therapy duration. The decision-making principle in compression therapy is to maintain correct sleeve placement and alignment to support effective blood flow promotion. This prevents complications like skin breakdown or ineffective DVT prevention. A transferable strategy is to inspect sleeve fit and positioning with each patient repositioning, adjusting as needed to sustain device effectiveness.
- A 79-year-old long-term care resident with limited mobility is using sequential compression devices (SCDs) for DVT prevention. The nurse assesses that the sleeves inflate and deflate regularly, the resident's calves are equal at 34 cm bilaterally, pedal pulses are present, and there is no redness or warmth; ankle edema remains at baseline 1+. Which observation indicates the compression device is working EFFECTIVELY?
Answer: The SCD sleeves cycle inflation and deflation as ordered while the resident is in bed
This question tests understanding of DVT prevention and recognition of effective compression device function. The priority concern is confirming that SCDs are providing appropriate intermittent pneumatic compression. Regular inflation and deflation cycles while the resident is in bed (Option A) indicates proper device function and effective DVT prophylaxis. Option B (elevated blood pressure) is unrelated to SCD effectiveness; Option C (tight feeling/non-use) indicates poor compliance; Option D (calf massage) is inappropriate and potentially dangerous if clots are present. The decision-making principle is that effective compression therapy requires consistent device function with regular compression cycles. A transferable strategy is to observe complete SCD cycles during assessments, document proper function, and address any patient concerns about comfort to ensure continuous use.
- A 59-year-old client is 1 day post-operative after a total knee replacement and is using compression stockings. The nurse notes the operative leg has 2+ edema at the ankle and calf circumference of 41 cm on the operative side versus 38 cm on the non-operative side; the client has been out of bed only once today. What is the PRIORITY nursing action for this client?
Answer: Remove the stocking and assess the leg for pain, warmth, color, and pulses, and report the increased swelling to the RN
This question tests understanding of DVT prevention and appropriate response to concerning findings in a post-operative knee replacement patient. The priority concern is recognizing potential DVT development in the operative leg with increased edema and asymmetric calf measurements. Removing the stocking to assess for pain, warmth, color changes, and pulses while reporting increased swelling to the RN (Option B) ensures proper evaluation of potential complications. Option A (rolling stocking tightly) could compromise circulation; Option C (massaging the calf) is contraindicated if DVT is suspected as it could dislodge a clot; Option D (keeping stocking off) removes necessary compression therapy. The decision-making principle is that new or worsening unilateral leg swelling post-operatively requires immediate assessment to rule out DVT. A transferable strategy is to perform comprehensive leg assessments before compression device application and when any changes occur, documenting and reporting concerning findings promptly.
- A 68-year-old client is 3 days post–knee replacement surgery and is using compression stockings. The nurse notes the toes are cool and pale on the operative side and the client reports tingling; pedal pulse is weaker than earlier. The nurse should REPORT which finding to the RN?
Answer: Cool, pale toes with tingling and a weaker pedal pulse compared with earlier assessment
This question tests understanding of DVT prevention and use of compression devices. The priority concern is signs of compromised circulation, such as cool, pale toes with tingling and weakened pulse, indicating possible over-compression or poor fit. Reporting cool, pale toes with tingling and a weaker pedal pulse compared with earlier assessment prompts RN evaluation to prevent tissue damage. Meal intake is unrelated; therapy inquiries are normal; mild indentation lines are expected. The decision-making principle in compression therapy is to monitor neurovascular status and report changes suggesting ischemia. This ensures safe and effective use postoperatively. A transferable strategy is to perform bilateral neurovascular checks, including pulse and sensation, every shift and report alterations to maintain device effectiveness.
- A 73-year-old long-term care resident with limited mobility is using SCDs for DVT prevention. The nurse notes the resident is transferred to a wheelchair for lunch, and the SCD sleeves remain connected and running while the legs are dependent; mild foot edema is present. What is the PRIORITY nursing action for this client?
Answer: Follow facility policy for SCD use out of bed and ensure the resident's legs are supported appropriately or the device is removed as directed
This question tests understanding of DVT prevention and use of compression devices. The priority concern is inappropriate use of SCDs in a dependent position during wheelchair transfer, which may exacerbate edema by countering compression benefits. Following facility policy for SCD use out of bed and ensuring proper leg support or removal optimizes safety and effectiveness. Increasing pressure risks harm; applying over shoes is improper; ordering a chest X-ray is unrelated to edema. The decision-making principle in compression therapy is to adhere to guidelines for device use in different positions to prevent complications. This maintains efficacy in mobility-limited residents. A transferable strategy is to review and apply positional protocols for compression devices during transfers, assessing edema afterward to ensure continued effectiveness.
- A 62-year-old post-operative knee replacement client is using compression stockings and is ambulating short distances with assistance. Assessment shows the affected leg has 1+ edema and calf circumference increased from 39 cm to 41 cm since morning; the client reports new calf pain rated 6/10. The nurse should REPORT which finding to the RN?
Answer: New calf pain with an increase in calf circumference since morning
This question tests understanding of DVT prevention and recognition of acute DVT symptoms in post-operative patients using compression stockings. The priority concern is identifying signs of possible DVT development despite prophylactic measures. New calf pain with increased circumference since morning (Option A) indicates potential DVT formation requiring immediate RN notification. Option B (extra blanket request) is a comfort measure; Option C (damp stocking) is expected with wear; Option D (food preferences) is unrelated to DVT risk. The decision-making principle is that new onset calf pain with measurable swelling progression requires immediate evaluation for possible DVT. A transferable strategy is to establish baseline measurements post-operatively and monitor for changes in circumference, especially when accompanied by new pain, warmth, or redness.
- A 79-year-old hospitalized client is on bed rest after a stroke and is using SCDs. Assessment shows toes are pink and warm, capillary refill is 2 seconds, and the SCD sleeves inflate and deflate every few minutes; calf circumferences are equal bilaterally with no edema. Which observation indicates the compression device is working effectively?
Answer: The sleeves cycle with regular inflation and deflation while the client is in bed
This question tests understanding of DVT prevention and use of compression devices. The priority concern is verifying that SCDs are functioning to prevent venous stasis in a bedridden client post-stroke. Observing the sleeves cycle with regular inflation and deflation while the client is in bed indicates effective operation by promoting blood flow through sequential compression. Stable blood pressure is unrelated to device function; feeling sleepy is not indicative; leaving sleeves off reduces effectiveness. The decision-making principle in compression therapy is to confirm visible and audible signs of proper cycling as evidence of efficacy. This supports ongoing DVT prevention. A transferable strategy is to log device cycling observations and patient leg assessments every 4 hours to ensure sustained effectiveness and early issue detection.
- A 72-year-old long-term care resident has limited mobility after a recent fall and a history of deep vein thrombosis (DVT). The resident is using a sequential compression device (SCD) while in bed; the nurse notes mild bilateral ankle edema (1+) and calf circumferences of 36 cm (right) and 36 cm (left). Which action is MOST important for ensuring the effectiveness of the compression device?
Answer: Verify the sleeves are the correct size and are snug without constricting, and that the pump is on and cycling as ordered
This question tests understanding of DVT prevention and proper use of sequential compression devices (SCDs) in long-term care residents with limited mobility. The priority concern is ensuring the SCD is functioning properly to provide effective DVT prophylaxis. Verifying correct sleeve size, proper fit (snug without constriction), and confirming the pump is cycling as ordered (Option B) ensures optimal compression therapy effectiveness. Option A (removing sleeves for sleep) defeats the purpose of continuous DVT prevention; Option C (heparin infusion) requires a physician order and is not within LPN scope; Option D (measuring I&O) relates to fluid balance but doesn't directly ensure SCD effectiveness. The decision-making principle is that mechanical compression devices must fit properly and function continuously to prevent venous stasis. A transferable strategy is to check SCD fit and function at every assessment, ensuring sleeves are properly sized, positioned, and the pump is cycling appropriately.
- A 60-year-old home health client is recovering after hip surgery and is at increased risk for DVT due to decreased mobility and smoking history. The nurse observes the caregiver applying compression stockings over a damp leg after a shower; mild redness is noted under the stocking top band. Which action is MOST important for ensuring the effectiveness of the compression device?
Answer: Teach to dry the skin completely and apply stockings smoothly without creating a tight band at the top
This question tests understanding of DVT prevention and use of compression devices. The priority concern is applying stockings over damp skin, which can cause irritation and uneven fit, compounded by tight bands leading to redness. Teaching to dry skin completely and apply smoothly without tight bands at the top ensures optimal use by preventing constriction and promoting even compression. Applying petroleum jelly increases slipping; rolling down creates tourniquets; stopping therapy ignores DVT risk. The decision-making principle in compression therapy is to ensure dry, smooth application to avoid skin issues and maintain efficacy. This is vital for at-risk clients like smokers. A transferable strategy is to include skin drying and application technique in caregiver education, with follow-up assessments to ensure device effectiveness.
