A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?

Keep the client's knees in a flexed position while they are in bed.

Massage the client's legs every 4 hr while they are awake.

Encourage the client to perform circumduction of the feet.

Limit the client's fluid intake to 2,000 mL daily.

Answer and Explanation

The Correct Answer is C

A)   Keeping the client's knees in a flexed position, is incorrect because prolonged immobility and knee flexion can increase the risk of VTE by impeding venous return.
B)   Massaging the client's legs, is not recommended as it may dislodge a potential clot that has formed, leading to a thromboembolic event.
C)   This exercise can help promote blood circulation and prevent clot formation without exerting excessive pressure on the surgical site.
D)   Adequate hydration is essential for preventing blood clots; dehydration can lead to hemoconcentration and increased risk of thrombosis.

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Correct Answer is D

Explanation

A. Covering electrical outlets with tape may not be sufficient for safety and could pose a fire hazard. Safety covers designed for outlets are recommended.
B. Keeping the client's bedroom dark at night may increase confusion and disorientation. Soft lighting or nightlights are preferable.
C. While a calendar may be helpful, placing it in the client's bedroom may not be as beneficial as placing it in a common area where the client spends time during the day.Furthermore, amonthly calendar can be too complex for clients with Alzheimer’s disease, especially in the later stages. Simpler tools like a daily schedule or a weekly calendar are more effective.
D. A large-face clock can help the client orient to time and reduce confusion regarding the time of day.

A. Obtain a board that uses colored pictures as communication. B. Request an interpreter during the initial assessment. C. Familiarize themselves with commonly used signed language. D. Ask a family member to be present during the admission.

Correct Answer is B

Explanation

A) Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B) Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C) Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.

D) Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.

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A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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