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 ["B","C"]

Explanation

Choice A reason:

This statement is correct. Regional anesthesia blocks the sensation of pain and other sensations from a specific part of the body, such as below the waist for spinal or epidural anesthesia. The client will not be able to move or feel anything in the affected area during the surgery.

Choice B reason:

This statement is incorrect. Regional anesthesia does not require the client to stay awake during the surgery, unless the client prefers to do so. The client can also receive sedation or general anesthesia along with regional anesthesia, depending on the type and duration of the surgery and the client's preference.

Choice C reason:

This statement is incorrect. Regional anesthesia can have residual effects on the client's motor and sensory function, as well as blood pressure and heart rate, for several hours after the surgery. The client will need someone to drive them home after the surgery and monitor them for any signs of complications.

Choice D reason:

This statement is correct. Regional anesthesia has some advantages over general anesthesia, such as less risk of nausea and vomiting, less blood loss, less stress response, and better postoperative pain control.

Choice E reason:

This statement is correct. Regional anesthesia does not affect the client's ability to swallow or protect their airway, unlike general anesthesia. However, the client will still have to fast for at least 8 hours before the surgery to prevent aspiration of stomach contents in case general anesthesia or sedation is needed or administered.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the informed consent form with a client who is scheduled for surgery with regional anesthesia. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

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

Explanation

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