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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:
Paralytic ileus can occur due to stress response but it’s not the immediate life-threatening issue.
Choice B rationale:
Airway obstruction is the immediate life-threatening issue due to swelling from burns in the head, neck, and chest area.
Choice C rationale:
Infection is a risk with burns but it’s not the immediate concern.
Choice D rationale:
Fluid imbalance is a concern due to loss from damaged skin but airway patency is the priority.

A. Complete a neurological check. B. Increase the client's fluid intake. C. Administer the prescribed PRN antihypertensive medication. D. Hold the client's evening dose of digoxin.

Correct Answer is A

Explanation

Choice A rationale:
Completing a neurological check is the correct action. The client’s sudden confusion and drowsiness could indicate a neurological issue, such as a stroke.
Choice B rationale:
Increasing the client’s fluid intake is not the first action to take. While dehydration can cause confusion, other causes need to be ruled out first.
Choice C rationale:
Administering the prescribed PRN antihypertensive medication is not the first action to take. The client’s blood pressure is not elevated, so this medication is not needed at this time.
Choice D rationale:
Holding the client’s evening dose of digoxin is not the first action to take. The client’s symptoms are not necessarily related to this medication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns on the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention.

Correct Answer is B

Explanation

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?

Correct Answer is A

Explanation

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