A nurse is caring for a client with a suspected stroke. Which of the following assessments should the nurse perform first?

Choice A reason: A clear liquid diet the day before a colonoscopy ensures the bowel is free of solid residue, allowing clear visualization of the colon mucosa. Clear liquids like broth, juice, or water do not leave particulate matter, facilitating effective bowel cleansing with laxatives, critical for accurate detection of polyps or abnormalities during the procedure.

Choice B reason: Taking antibiotics the morning of a colonoscopy is not standard practice. Antibiotics are not routinely required for bowel preparation, as the procedure carries a low infection risk. They may be used in specific cases, like patients with heart valve conditions, but this is not a general instruction for colonoscopy preparation.

Choice C reason: Drinking milk is contraindicated during colonoscopy preparation. Milk is not a clear liquid and leaves residue in the bowel, obstructing visualization during the procedure. A clear liquid diet is required to ensure the colon is clean, as dairy products can interfere with effective bowel cleansing and diagnostic accuracy.

Choice D reason: Avoiding water during bowel prep is incorrect. Adequate hydration is essential during colonoscopy preparation to prevent dehydration from laxative-induced fluid loss. Drinking water supports bowel cleansing and maintains electrolyte balance, ensuring patient safety and comfort during the prep process and the procedure itself.

Choice A reason: Active leg exercises promote venous return by activating the calf muscle pump, preventing blood stasis in the lower extremities. Stasis is a key component of Virchow’s triad, increasing the risk of deep vein thrombosis (DVT), which can lead to pulmonary embolism. Regular movement enhances circulation, reducing clot formation in postoperative patients.

Choice B reason: Maintaining the head of the bed at 90 degrees does not directly reduce pulmonary embolism risk. While it may improve respiratory function, it does not address venous stasis or clot formation in the lower extremities, the primary source of pulmonary emboli. This position may also increase discomfort or orthostatic hypotension in some patients.

Choice C reason: Early ambulation enhances venous blood flow by engaging leg muscles, reducing stasis, a major risk factor for deep vein thrombosis and subsequent pulmonary embolism. Postoperative immobility increases clot formation risk, so mobilizing the client soon after surgery, when safe, significantly lowers the likelihood of thromboembolic events in the pulmonary vasculature.

Choice D reason: Aspirin and warfarin are anticoagulants that reduce clotting risk, but their use must be carefully considered due to bleeding risks in postoperative patients. They are not first-line interventions compared to mechanical methods like leg exercises or compression stockings. Their administration requires specific medical orders and monitoring, making them less immediate for prevention.

Choice E reason: Compression stockings apply graduated pressure to the legs, promoting venous return and preventing blood pooling, which reduces the risk of deep vein thrombosis formation. By counteracting stasis, they help prevent clots that could dislodge and cause a pulmonary embolism, making them an effective, non-invasive intervention for postoperative patients.