Nclexpn Quiz: Compression Devices And Dvt Prevention
20 questions · exam conditions
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Compression Devices And Dvt PreventionQuestion 1 of 20

A 77-year-old long-term care resident with obesity and limited mobility is prescribed sequential compression devices (SCDs) when in bed. The nurse finds the SCD pump turned on, but the sleeves are loosely wrapped and sliding down; the resident has 1+ edema and calf circumferences are equal at 35 cm bilaterally. Which action is MOST important for ensuring the effectiveness of the compression device?

Rewrap and refasten the sleeves so they fit snugly, then confirm the pump inflates and deflates at the ordered setting
Apply powder under the sleeves to prevent sweating and leave the loose fit for comfort
Ask the RN to discontinue SCDs and switch to anti-embolism stockings
Place a pillow under the knees to keep the sleeves from sliding
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Nclexpn Quiz: Compression Devices And Dvt Prevention

Practice Compression Devices And Dvt Prevention in Nclexpn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

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Question 1

A 77-year-old long-term care resident with obesity and limited mobility is prescribed sequential compression devices (SCDs) when in bed. The nurse finds the SCD pump turned on, but the sleeves are loosely wrapped and sliding down; the resident has 1+ edema and calf circumferences are equal at 35 cm bilaterally. Which action is MOST important for ensuring the effectiveness of the compression device?

  1. Rewrap and refasten the sleeves so they fit snugly, then confirm the pump inflates and deflates at the ordered setting (correct answer)
  2. Apply powder under the sleeves to prevent sweating and leave the loose fit for comfort
  3. Ask the RN to discontinue SCDs and switch to anti-embolism stockings
  4. Place a pillow under the knees to keep the sleeves from sliding

Explanation: This question tests understanding of DVT prevention and ensuring proper SCD application in obese residents with limited mobility. The priority concern is that loosely fitted SCDs provide inadequate compression for DVT prevention. Rewrapping sleeves for snug fit and confirming pump function at ordered settings (Option A) ensures the device provides therapeutic compression. Option B (powder application with loose fit) maintains ineffective compression; Option C (switching to stockings) requires physician order and may be less effective for this patient; Option D (pillow under knees) could impede venous return and doesn't address the loose fit. The decision-making principle is that SCDs must maintain proper fit throughout use to provide effective intermittent pneumatic compression. A transferable strategy is to check SCD placement and fit at regular intervals, especially in patients with obesity where sleeves may slide more easily, and readjust as needed.

Question 2

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?

  1. Leave both devices in place to maximize compression and reassess in 4 hours
  2. Remove the SCD sleeves and keep the stockings on only until the redness resolves
  3. Remove the devices, assess skin and circulation, then reapply the SCDs correctly per facility policy and report the skin redness to the RN (correct answer)
  4. Ask the RN to prescribe a topical antibiotic for the redness

Explanation: This question tests understanding of DVT prevention and proper compression device application to prevent skin complications. The priority concern is addressing improper device layering that has caused skin irritation at pressure points. Removing devices, assessing skin and circulation, reapplying SCDs correctly per policy, and reporting skin redness (Option C) ensures safe compression therapy while addressing the complication. Option A (leaving both devices) continues harmful pressure; Option B (keeping only stockings) may provide inadequate compression; Option D (topical antibiotic) doesn't address the mechanical cause. The decision-making principle is that compression devices should never be layered as this creates excessive pressure and skin breakdown risk. A transferable strategy is to ensure only one type of compression device is used at a time, following facility protocols for device selection based on patient mobility and risk factors.

Question 3

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?

  1. Apply the compression stocking by rolling it into a tight band and stretching it over the calf quickly
  2. Remove the stocking and assess the leg for pain, warmth, color, and pulses, and report the increased swelling to the RN (correct answer)
  3. Massage the calf firmly to improve circulation before reapplying the stocking
  4. Keep the stocking off for the rest of the shift to prevent skin irritation

Explanation: 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.

Question 4

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?

  1. Apply a warm compress to the calf and reassess in 2 hours
  2. Massage the calf gently to reduce tenderness
  3. Encourage the client to perform vigorous ankle circles to break up a possible clot
  4. Stop using the SCD on the affected leg and report the findings to the RN promptly (correct answer)

Explanation: 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.

Question 5

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?

  1. The SCD sleeves cycle inflation and deflation as ordered while the resident is in bed (correct answer)
  2. The resident's blood pressure is 148/86 mm Hg after breakfast
  3. The resident reports the sleeves feel very tight and leaves them off most of the day
  4. The nurse massages the calves each shift to improve circulation

Explanation: 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.

Question 6

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?

  1. New calf pain with an increase in calf circumference since morning (correct answer)
  2. Client requests an extra blanket for warmth
  3. Compression stocking fabric feels slightly damp from perspiration
  4. Client states the hospital food is not appealing

Explanation: 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.

Question 7

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?

  1. Remove the SCD sleeves once per shift to allow uninterrupted sleep
  2. Verify the sleeves are the correct size and are snug without constricting, and that the pump is on and cycling as ordered (correct answer)
  3. Request an order from the RN to start a heparin infusion for DVT prevention
  4. Measure the resident's oral intake and output each shift to evaluate edema

Explanation: 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.

Question 8

A 58-year-old client is 2 days post–knee replacement surgery in the hospital. The client has obesity and is ambulating short distances with a walker; compression stockings are in place. The nurse notes the operative leg calf circumference increased from 40 cm to 43 cm since morning with 2+ edema. What is the PRIORITY nursing action for this client?

  1. Encourage increased oral fluids and recheck the circumference at end of shift
  2. Massage the calf to improve circulation while the stockings are on
  3. Remove the stocking and reapply it loosely to reduce pressure
  4. Report the increased calf circumference and swelling to the RN for further evaluation (correct answer)

Explanation: This question tests understanding of DVT prevention and use of compression devices. The priority concern is identifying potential postoperative DVT indicated by increased calf circumference and edema in the operative leg, which requires escalation for evaluation. Reporting the increased calf circumference and swelling to the RN ensures optimal assessment and possible intervention to rule out thrombosis. Massaging the calf could dislodge a clot; reapplying loosely reduces compression effectiveness; encouraging fluids and rechecking later delays necessary action. The decision-making principle in compression therapy is to prioritize reporting signs of complications like unilateral swelling over independent adjustments to the device. This approach prevents progression to serious events like embolism. A transferable strategy is to document baseline and ongoing measurements of leg circumferences and edema, reporting changes promptly to maintain effective DVT prevention.

Question 9

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?

  1. Client requests an extra blanket because the room feels cold
  2. Client states they are tired after physical therapy
  3. Stockings are clean and dry with no visible wrinkles
  4. Client reports new unilateral calf pain with increased calf circumference compared to the other leg (correct answer)

Explanation: 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.

Question 10

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?

  1. Ask the caregiver to double the stockings for extra compression
  2. Teach the caregiver to avoid rolling the stockings down and to smooth them flat to prevent a tight band (correct answer)
  3. Request the RN to prescribe a new pain medication before using stockings
  4. Tell the caregiver to apply the stockings only when swelling is present

Explanation: 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.

Question 11

A 71-year-old client is 1 day post–knee replacement surgery and is using compression stockings. The nurse notes the stockings are applied, but the heel area is folded and creating a crease; skin is intact and the client is mostly in bed. Which action is MOST important for ensuring the effectiveness of the compression device?

  1. Apply the stockings only during physical therapy sessions
  2. Leave the crease in place to prevent the stocking from sliding
  3. Remove and reapply the stockings smoothly without creases, ensuring correct size and alignment (correct answer)
  4. Ask the RN to order a diuretic to reduce swelling

Explanation: This question tests understanding of DVT prevention and use of compression devices. The priority concern is creases in compression stockings, which can create pressure points and impair even compression in a postoperative client. Removing and reapplying smoothly without creases, ensuring correct size and alignment, optimizes use by providing uniform pressure to promote venous flow. Leaving the crease risks skin damage; ordering a diuretic addresses swelling not device issues; applying only during therapy limits benefits. The decision-making principle in compression therapy is to correct application errors immediately to maintain safe and effective compression. This supports DVT prevention without harm. A transferable strategy is to inspect stockings for folds or misalignments during each assessment and reapply as needed to ensure ongoing effectiveness.

Question 12

A 57-year-old client is 2 days post–knee replacement surgery and is wearing compression stockings. The nurse notes sudden shortness of breath when the client returns to bed, respiratory rate 26/min, and the operative calf circumference is 3 cm larger than the other leg. The nurse should REPORT which finding to the RN?

  1. Sudden shortness of breath with increased respiratory rate and unilateral calf enlargement (correct answer)
  2. Client requests to delay the next walk until after a nap
  3. Stockings appear slightly damp after bathing
  4. Client rates incision pain as 4/10

Explanation: This question tests understanding of DVT prevention and use of compression devices. The priority concern is symptoms suggesting pulmonary embolism from DVT, such as sudden shortness of breath and unilateral calf enlargement, requiring urgent reporting. Reporting sudden shortness of breath with increased respiratory rate and unilateral calf enlargement facilitates immediate intervention. Requesting to delay walking is unrelated; damp stockings post-bath are minor; incision pain is expected. The decision-making principle in compression therapy is to recognize and report systemic signs linked to leg asymmetry as potential complications. This prevents fatal outcomes postoperatively. A transferable strategy is to monitor respiratory status alongside leg assessments, reporting combined changes urgently to ensure effective DVT management.

Question 13

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?

  1. Place a pillow directly behind the knees to improve comfort during inflation
  2. Remove both sleeves and apply them again at the end of the shift
  3. Ask the RN to prescribe a sedative so the client tolerates the device better
  4. Unkink the tubing, ensure connections are secure, and verify the sleeve inflates and deflates properly (correct answer)

Explanation: 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.

Question 14

A 66-year-old hospitalized client is immobile after a stroke and has SCDs ordered. The nurse notes the client has 2+ pedal pulses, but the SCD sleeves are applied over thick, wrinkled socks. Which action is MOST important for ensuring the effectiveness of the compression device?

  1. Ask the RN to order antiembolism stockings instead of SCDs
  2. Remove the thick socks and apply the sleeves directly over the skin or thin barrier per facility policy, smoothing wrinkles (correct answer)
  3. Tighten the sleeves as much as possible to prevent them from sliding
  4. Turn the pump off during meals to reduce noise

Explanation: This question tests understanding of DVT prevention and use of compression devices. The priority concern is improper application of SCDs over thick, wrinkled socks, which can reduce compression efficacy and cause uneven pressure. Removing the thick socks and applying sleeves directly or with a thin barrier, smoothing wrinkles, ensures optimal fit and pressure distribution for venous return. Tightening excessively risks circulation impairment; turning off during meals interrupts therapy; switching to stockings may not be indicated. The decision-making principle in compression therapy is to ensure direct skin contact or minimal barriers for effective compression. This prevents slippage and maintains function. A transferable strategy is to check for barriers like clothing under devices during application and adjust immediately to ensure proper effectiveness.

Question 15

A 64-year-old home health client is recovering after hip surgery with decreased mobility and is using compression stockings. The nurse notes the caregiver applied the stockings, but the client's toes are not visible because the foot portion is pulled over them; the client reports the toes feel cold. Which action is MOST important for ensuring the effectiveness of the compression device?

  1. Request the RN to order a higher compression stocking immediately
  2. Tell the client to wiggle toes for 5 minutes and leave the stockings as they are
  3. Reapply the stockings so toe color, warmth, and circulation can be assessed and the foot portion is positioned correctly (correct answer)
  4. Apply an extra pair of socks over the stockings to warm the toes

Explanation: This question tests understanding of DVT prevention and use of compression devices. The priority concern is misapplication of stockings covering toes, preventing circulation assessment and potentially causing coldness from poor fit. Reapplying so toes are visible and positioned correctly allows monitoring and ensures optimal compression without constriction. Telling to wiggle toes is insufficient; adding socks may worsen issues; ordering higher compression ignores current errors. The decision-making principle in compression therapy is to ensure visible access for assessments and correct positioning for safe use. This supports effective DVT prevention at home. A transferable strategy is to verify toe exposure and temperature during stocking checks, educating caregivers on reapplication to maintain device effectiveness.

Question 16

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?

  1. Client prefers the room temperature cooler than usual
  2. Client requests to keep the SCDs on while sitting in the chair
  3. SCD sleeves leave faint, temporary indentations on the skin after cycling
  4. Right calf circumference is 4 cm larger than the left with warmth and new swelling (correct answer)

Explanation: 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.

Question 17

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?

  1. Apply powder under the sleeves to reduce sweating
  2. Remove the sleeves whenever the resident is awake to improve comfort
  3. Assist the resident to keep legs supported in bed or in a chair with legs elevated as appropriate while SCDs are in use (correct answer)
  4. Increase the inflation time to keep pressure on the legs longer

Explanation: This question tests understanding of DVT prevention and use of compression devices. The priority concern is suboptimal leg positioning during SCD use, as dangling legs can counteract compression benefits by promoting venous pooling. Assisting the resident to keep legs supported in bed or elevated in a chair as appropriate while SCDs are in use optimizes effectiveness by enhancing venous return alongside compression. Applying powder may cause issues; increasing inflation time alters settings; removing when awake reduces therapy. The decision-making principle in compression therapy is to combine proper positioning with device use for synergistic DVT prevention. This is key in limited-mobility residents. A transferable strategy is to integrate leg elevation protocols with SCD application checks to ensure comprehensive effectiveness in preventing stasis.

Question 18

A 76-year-old long-term care resident with dementia and limited mobility is using SCDs in bed for DVT prevention. The nurse assesses that the sleeves are on, but the pump is off and the tubing is disconnected; pedal pulses are 2+ bilaterally and skin is intact. Which action is MOST important for ensuring the effectiveness of the compression device?

  1. Apply lotion under the sleeves to prevent dryness
  2. Ask the RN to discontinue SCDs because the resident is confused
  3. Reconnect the tubing and turn the pump on, verifying the sleeves inflate and deflate as ordered (correct answer)
  4. Keep the sleeves off during the day so the resident can move more freely in bed

Explanation: This question tests understanding of DVT prevention and use of compression devices. The priority concern is restoring the function of SCDs in a resident with dementia who may inadvertently disconnect them, to maintain venous flow and prevent stasis. Reconnecting the tubing and turning the pump on, verifying inflation and deflation as ordered, ensures optimal use by resuming sequential compression essential for DVT prophylaxis. Applying lotion could cause slipping or skin issues; discontinuing due to confusion ignores the need for prevention; keeping off during the day reduces overall therapy time. The decision-making principle in compression therapy is to promptly correct any disruptions in device function to sustain continuous protection against thrombosis. This is especially vital in vulnerable populations like those with dementia. A transferable strategy is to educate staff on quick reconnection protocols and monitor device status hourly in high-risk patients to ensure consistent effectiveness.

Question 19

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?

  1. Client has a bowel movement once daily
  2. Numbness in toes with dusky color while SCDs are inflating (correct answer)
  3. Client requests water at bedside
  4. SCD pump makes a soft clicking sound during cycling

Explanation: 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.

Question 20

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?

  1. Stockings are removed for most of the day to improve comfort
  2. Client's pain score decreases after receiving analgesics
  3. Leg swelling remains minimal and calf circumferences stay equal without new warmth or redness (correct answer)
  4. Client's appetite improves at dinner

Explanation: 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.