A nurse is caring for a patient who had spinal surgery and is at risk for deep vein thrombosis (DVT) Which of the following nursing interventions is most effective in preventing DVT?

Applying sequential compression devices to the lower extremities.

Massaging the calves and thighs gently.

Elevating the foot of the bed by 15 degrees.

Encouraging early ambulation and leg exercises.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Applying sequential compression devices (SCDs) to the lower extremities is the most effective nursing intervention in preventing DVT in a patient who had spinal surgery and is at risk for DVT. SCDs are pneumatic devices that inflate and deflate around the legs to promote venous return and prevent stasis of blood, which can lead to clot formation.

Choice B reason:

Massaging the calves and thighs gently is not recommended for a patient who had spinal surgery and is at risk for DVT. Massaging the affected area can dislodge a clot and cause a pulmonary embolism, which is a life-threatening complication of DVT.

Choice C reason:

Elevating the foot of the bed by 15 degrees is not an effective nursing intervention in preventing DVT in a patient who had spinal surgery and is at risk for DVT. Elevating the foot of the bed can increase venous stasis and impair circulation, which can increase the risk of clot formation.

Choice D reason:

Encouraging early ambulation and leg exercises is an effective nursing intervention in preventing DVT in a patient who had spinal surgery and is at risk for DVT, but not as effective as applying SCDs. Early ambulation and leg exercises can improve blood flow and prevent venous stasis, but they may not be feasible or safe for some patients who had spinal surgery, depending on their level of injury and mobility.

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Correct Answer is A

Explanation

Choice A reason:

The nurse should call for assistance and stay with the client because the client is likely experiencing wound evisceration, which is a surgical emergency that requires immediate intervention. Wound evisceration is the protrusion of bowel through an abdominal incision, and it can occur 4 to 5 days postoperatively following an increase in strain on the incision, such as from turning, coughing, sneezing, or vomiting. Clients often report feeling something has "popped”. or opened in the wound, followed by severe pain and a sensation of wetness. The nurse should not leave the client alone or attempt to reinsert the bowel.

Choice B reason:

The nurse should not remove the dressing to assess the wound because this could increase the risk of infection and further injury to the wound. The nurse should cover the wound with a nonadherent dressing moistened with warm sterile normal saline to protect the wound from contamination and drying. Removing the dressing could also cause more pain and bleeding to the client.

Choice C reason:

The nurse should not cover the wound with sterile towels soaked in sterile saline because this could cause maceration of the skin and increase the risk of infection. The nurse should use a nonadherent dressing moistened with warm sterile normal saline to prevent adherence to the wound and allow for drainage. Sterile towels could also be too bulky and heavy for the wound.

Choice D reason:

The nurse should not assess vital signs as the first action because this would delay the urgent care needed for the client. The nurse should call for assistance and stay with the client while covering the wound with a nonadherent dressing moistened with warm sterile normal saline. Assessing vital signs can be done after securing help and stabilizing the wound. Vital signs may show signs of shock, such as hypotension, tachycardia, tachypnea, and pallor. A) Call for assistance and stay with client. B) Remove dressing to assess wound. C) Cover wound with sterile towels soaked in sterile saline. D) Assess vital signs.

A. Shivering. B. Tachycardia. C. Pallor. D. Diaphoresis. E. Hypotension.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason:

Shivering is a sign of hypothermia because it is the body's way of generating heat when the core temperature drops below normal. Shivering can be uncontrollable in mild hypothermia and may stop in moderate to severe hypothermia as the body conserves energy.

Choice B reason:

Tachycardia is not a sign of hypothermia. In fact, hypothermia can cause bradycardia, which is a slow heart rate, as the body tries to reduce heat loss through the blood vessels.

Choice C reason:

Pallor is a sign of hypothermia because it indicates reduced blood flow to the skin as the blood vessels constrict to preserve core temperature. Pallor can also be accompanied by cyanosis, which is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood.

Choice D reason:

Diaphoresis is a sign of hypothermia because it is the result of excessive sweating that can occur after exposure to cold or wet environments. Sweating can increase heat loss through evaporation and lower the body temperature further.

Choice E reason:

Hypotension is a sign of hypothermia because it reflects decreased cardiac output and blood pressure as the heart muscle becomes less efficient and responsive to stimuli. Hypotension can also lead to shock, organ failure, and death if not treated promptly.

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A nurse is caring for a patient who had spinal surgery and is at risk for deep vein thrombosis (DVT) Which of the following nursing interventions is most effective in preventing DVT?

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Correct Answer is A

Explanation

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Explanation

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