Nokea
The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk?
- A. Encourage independence with ADLs whenever possible.
- B. Monitor the patient's nutritional status closely.
- C. Teach the patient to perform ankle and foot exercises within the limitations of traction.
- D. Administer clopidogrel (Plavix) as ordered.
Correct Answer: C
Rationale: The nurse educates the patient how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. Nutrition is important, but does not directly prevent DVT. Similarly, independence with ADLs should be promoted, but this does not confer significant prevention of DVT, which often affects the lower limbs. Plavix is not normally used for DVT prophylaxis.
You may also like to solve these questions
A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patient's statements would indicate to the nurse that the patient requires further teaching?
- A. I'll need to keep several pillows between my legs at night.
- B. I need to remember not to cross my legs. It's such a habit.
- C. The occupational therapist is showing me how to use a sock puller to help me get dressed.
- D. I will need my husband to assist me in getting off the low toilet seat at home.
Correct Answer: D
Rationale: To prevent hip dislocation after a total hip replacement, the patient must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the patient to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a patient get dressed without flexing the hips beyond 90 degrees.
A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions?
- A. Shifting one's weight in bed
- B. Bearing down while having a bowel movement
- C. Turning from side to side
- D. Coughing without splinting
Correct Answer: C
Rationale: To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance. Bearing down and coughing do not pose a threat to bone union.
While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient?
- A. Risk for Infection
- B. Risk for Peripheral Neurovascular Dysfunction
- C. Unilateral Neglect
- D. Disturbed Kinesthetic Sensory Perception
Correct Answer: B
Rationale: The hematoma may cause an interruption of tissue perfusion, so the most appropriate nursing diagnosis is Risk of Peripheral Neurovascular Dysfunction. There is also an associated risk for infection because of the hematoma, but impaired neurovascular function is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than neurovascular status.
A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient?
- A. Keep the patient's hips in abduction at all times.
- B. Keep hips flexed at no less than 90 degrees.
- C. Elevate the head of the bed to high Fowler's.
- D. Seat the patient in a low chair as soon as possible.
Correct Answer: A
Rationale: The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The patient's hips should be higher than the knees; as such, high seat chairs should be used.
A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize?
- A. Make sure you don't bring your knees close together.
- B. Try to lie as still as possible for the first few days.
- C. Try to avoid bending your knees until next week.
- D. Keep your legs higher than your chest whenever you can.
Correct Answer: A
Rationale: After receiving a hip prosthesis, the affected leg should be kept abducted. Mobility should be encouraged within safe limits. There is no need to avoid knee flexion and the patient's legs do not need to be higher than the level of the chest.