A nurse is caring for a client who is postoperative following cardiac surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

(A) "I’ll breathe deeply and cough every 4 hours."
Deep breathing and coughing exercises should be done more frequently, typically every 1-2 hours while awake, to help prevent respiratory complications such as atelectasis and pneumonia.

(B) "I’ll splint my incision with a pillow to cough."
This statement indicates an understanding of the instructions. Splinting the incision with a pillow helps support the surgical site, reduces pain, and makes coughing more effective and less uncomfortable. This technique is important for clients to use to help clear secretions from the lungs postoperatively.

(C) "I’ll start to use the incentive spirometer when I can get out of bed."
The use of an incentive spirometer should begin as soon as possible, usually while the client is still in bed, to encourage deep breathing and prevent postoperative respiratory complications. It should not be delayed until the client can get out of bed.

(D) "I’ll lie flat in bed to cough and deep breathe."
Lying flat is not the optimal position for deep breathing and coughing exercises, as it can make it more difficult to fully expand the lungs. The client should be positioned with the head of the bed elevated or sitting up to facilitate better lung expansion and more effective coughing.

A. Root cause analysis:

Root cause analysis is a method used to identify the underlying causes of adverse events or errors. While it is important for quality improvement and risk management, it does not specifically involve using research and scientific data to guide clinical decision-making in client care.

B. Evidence-based practice:

Evidence-based practice (EBP) involves integrating the best available evidence from research studies with clinical expertise and patient preferences to guide decision-making in client care. By utilizing research and scientific data, nurses can identify effective interventions and strategies to improve client outcomes.

C. Benchmarking:

Benchmarking involves comparing performance metrics or outcomes against standards or best practices. While benchmarking can inform quality improvement efforts, it does not directly involve using research and scientific data to guide clinical decision-making.

D. Standardization:

Standardization involves implementing consistent processes or protocols to improve quality and safety. While standardization is important for ensuring consistency in care delivery, it does not necessarily rely on research and scientific data to inform clinical decision-making as evidence-based practice does.