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 C

Explanation

Choice A reason:

Covering the wound with sterile gauze moistened with normal saline is a correct nursing intervention for wound evisceration, but it is not the priority action. The priority is to get immediate help and inform the surgeon of the situation.

Choice B reason:

Placing the patient in low Fowler's position with knees bent is another correct nursing intervention for wound evisceration, as it reduces tension on the abdominal muscles and prevents further protrusion of the bowel. However, it is not the priority action either.

Choice C reason:

Calling for assistance and notifying the surgeon is the priority nursing intervention for wound evisceration, as this is a surgical emergency that requires prompt intervention to prevent complications such as infection, necrosis, or shock. The nurse should also monitor the patient's vital signs and prepare for possible surgery.

Choice D reason:

Applying pressure to the wound edges is an incorrect nursing intervention for wound evisceration, as it can cause further damage to the bowel and increase the risk of infection. The nurse should avoid touching or manipulating the wound or the bowel.

A. Remove dentures, glasses, contact lenses, jewelry and nail polish. B. Administer a sedative or anxiolytic medication as prescribed. C. Mark the surgical site with an indelible marker. D. All of the above.

Correct Answer is D

Explanation

Choice A reason:

Removing dentures, glasses, contact lenses, jewelry and nail polish is part of the physical preparation of the client before surgery. These items can interfere with the anesthesia, cause injury, or be lost during the procedure.

Choice B reason:

Administering a sedative or anxiolytic medication as prescribed is part of the preoperative medication of the client before surgery. These medications can help reduce anxiety, pain, nausea, and vomiting, and facilitate induction of anesthesia.

Choice C reason:

Marking the surgical site with an indelible marker is part of the patient identification and verification process before surgery. This helps prevent wrong-site, wrong-procedure, or wrong-person surgery by ensuring that the correct site is marked and confirmed by the client, surgeon, and nurse.

Choice D reason:

All of the above. All of these items should be completed before transferring the client to the operating room as part of the preoperative checklist. The checklist ensures that necessary documentation, admission assessment, physical preparation, and client education have been completed before the client enters the surgical suite.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

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