A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombosis?
Deep breathing and coughing exercises daily
Removal of compression stockings at night
Floating the heels while lying in bed
Leg exercises ten times per hour while awake
The Correct Answer is D
A. Deep breathing and coughing exercises daily: These are important for preventing respiratory complications but do not specifically address the prevention of thrombosis.
B. Removal of compression stockings at night: Compression stockings should generally be worn continuously to prevent venous stasis and thrombosis.
C. Floating the heels while lying in bed: This helps prevent pressure ulcers but is not a primary intervention for preventing thrombosis.
D. Leg exercises ten times per hour while awake: This is the correct choice. Regular leg exercises improve circulation and help prevent venous stasis, thereby reducing the risk of thrombosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Chest x-ray results: This is the correct choice. After central venous catheter insertion, a chest x-ray is crucial to confirm correct catheter placement and to rule out complications such as pneumothorax or catheter malposition.
B. Serum osmolality: While serum osmolality can provide information about fluid and electrolyte balance, it is not directly related to verifying catheter placement or the immediate post-insertion assessment.
C. Intake and output record: Although important for monitoring fluid balance, the intake and output record does not confirm the proper placement of the central venous catheter.
D. Serum glucose level: This is not relevant to verifying the catheter placement or ensuring proper functioning immediately after insertion.
Correct Answer is A
Explanation
A. Serum potassium 3.2 mEq/L: A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L) and indicates hypokalemia, which can cause serious cardiac arrhythmias and muscle weakness. This condition requires prompt correction and collaboration with the healthcare provider before surgery to avoid intraoperative and postoperative complications.
B. Pulse rate 65 bpm: A pulse rate of 65 bpm is within the normal range (60-100 bpm). While it should be monitored, it does not require immediate intervention or collaboration with the healthcare provider before surgery.
C. Hematocrit 36%: A hematocrit level of 36% is within the lower end of the normal range (35-45% for women). This does not indicate an immediate concern that requires prompt collaboration with the healthcare provider.
D. Blood pressure 144/82 mmHg: Although this blood pressure reading is slightly elevated, it is not uncommon and can be managed perioperatively. It does not require immediate intervention before surgery.
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