Nokea
A nurse is caring for a postoperative patient who has been on bedrest for 5 days. What interventions will the nurse use to prevent deep vein thrombosis (DVT)? Select all that apply.
- A. Administering analgesics
- B. Documenting daily calf circumference
- C. Assessing vital signs every 4 hours
- D. Encouraging ambulation
- E. Applying intermittent pneumatic compression devices (IPCDs)
- F. Providing education on pain management
Correct Answer: D,E
Rationale: To prevent DVT, the nurse plans to apply an IPCD and antiembolism stockings. Assessments such as vital signs and calf circumference will detect but not prevent DVT. Maintaining bedrest continues to promote risk, and early ambulation helps prevent DVT.
You may also like to solve these questions
A nurse is preparing a patient for same-day surgery. Which of these patient-related findings must the nurse report immediately?
- A. Asking how long after the surgery they can leave the hospital
- B. Received an oral anticoagulant last night
- C. Surgeon has not yet filled out the consent form
- D. Blood pressure is 142/86
Correct Answer: B
Rationale: Patients receiving anticoagulants are at risk for bleeding or hemorrhage during invasive and surgical procedures. Wanting to know an anticipated discharge date is expected, the surgeon can fill out the consent form prior to sedation, and a slight increase in blood pressure is possible related to anxiety before surgery.
An older adult who is scheduled for a hip replacement is taking several medications on a regular basis. Which group of medications does the nurse identify as a surgical risk for this patient?
- A. Anticoagulants
- B. Antacids
- C. Laxatives
- D. Sedatives
Correct Answer: A
Rationale: Anticoagulant medications increase the risk for hemorrhage intra- and postoperatively.
A nurse teaches a patient the rationale for performing leg exercises after surgery. How does the nurse best explain the purpose of the exercises to the patient?
- A. Improves respiratory function
- B. Maintains functional abilities
- C. Provides diversional activities
- D. Increases venous return
Correct Answer: D
Rationale: Leg exercises promote venous return and decrease complications related to venous stasis causing DVT and help prevent muscle weakness. These exercises also decrease risk for thrombophlebitis and emboli.
A nurse on a surgical unit is aware that older adults develop reduced vital capacity as a result of normal physiologic changes. Based on these changes, which nursing intervention takes priority?
- A. Taking and recording vital signs every shift
- B. Turning, coughing, and deep breathing every 4 hours
- C. Encouraging increased intake of oral fluids
- D. Assessing bowel sounds daily
Correct Answer: B
Rationale: Reduced vital capacity in older adults decreases respiratory expansion, increasing the risk for pneumonia and atelectasis. Encouraging the patient to turn, cough, and deep breathe every 4 hours helps to prevent complications.
An adult patient awaiting surgery says to the nurse, 'I am so frightened-what if I don't wake up?' What is the nurse's best response?
- A. Are you worried about the anesthesia?
- B. Tell me what concerns you most.
- C. Your surgeon is great; she operated on my aunt!
- D. Many people are anxious before surgery.
Correct Answer: B
Rationale: An open-ended question that allows the patient to express concerns, fears, and feelings is therapeutic and most appropriate. The other options suggest 'yes/no' answers or suggest issues that may not be present. This type of communication does not allow the patient to clarify their thoughts.