A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?
Ambulating soon after surgery.
Massaging her legs.
Flexing her ankles.
Elevating her feet.
The Correct Answer is B
Choice A rationale:
Ambulating soon after surgery is actually encouraged as it promotes blood flow and reduces the risk of VTE.
Choice B rationale:
Massaging the legs can dislodge a clot if one has formed, leading to a VTE.
Choice C rationale:
Flexing the ankles promotes blood flow and reduces the risk of VTE.
Choice D rationale:
Elevating the feet can reduce swelling and promote venous return, reducing the risk of VTE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Ambulating soon after surgery is actually encouraged as it promotes blood flow and reduces the risk of VTE.
Choice B rationale:
Massaging the legs can dislodge a clot if one has formed, leading to a VTE.
Choice C rationale:
Flexing the ankles promotes blood flow and reduces the risk of VTE.
Choice D rationale:
Elevating the feet can reduce swelling and promote venous return, reducing the risk of VTE.
Correct Answer is B
Explanation
Choice A rationale:
Applying a cold pack to the client’s upper arm would not be the first action to take. It may help reduce swelling, but it does not address the underlying issue.
Choice B rationale:
Measuring the circumference of both upper arms is the correct first action. This will provide objective data about the extent of the swelling, which can then be reported to the healthcare provider.
Choice C rationale:
Removing the PICC line is not the first action to take. This should only be done under the direction of a healthcare provider.
Choice D rationale:
Notifying the provider who inserted the PICC line is important, but it should be done after gathering all necessary data, including measuring the arm circumference.
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