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 D

Explanation

Choice A reason:

Wearing tight-fitting clothing or jewelry on the affected arm is not recommended, but it is not something to avoid completely. Tight-fitting clothing or jewelry can cause swelling (lymphedema) or infection in the arm, but wearing them for short periods of time may be acceptable. The client should be advised to wear loose-fitting clothing and jewelry most of the time and to monitor the arm for any signs of swelling, pain, or redness.

Choice B reason:

Elevating the affected arm above the level of the heart is not something to avoid, but rather something to do frequently. Elevating the arm can help reduce swelling and improve blood flow. The client should be instructed to elevate the arm several times a day for 15 to 30 minutes at a time.

Choice C reason:

Applying moisturizer or sunscreen to the affected arm is not something to avoid, but rather something to do regularly. Moisturizer can help prevent dryness and cracking of the skin, which can increase the risk of infection. Sunscreen can help protect the skin from sun damage, which can also increase the risk of infection and skin cancer. The client should be advised to apply moisturizer daily and sunscreen whenever exposed to the sun.

Choice D reason:

Having blood pressure or blood draws on the affected arm is something to avoid. This is because these procedures can cause injury or infection to the arm, which can lead to lymphedema or other complications. The client should be instructed to inform all health care providers that they had a mastectomy with lymph node dissection and to request that blood pressure or blood draws be done on the other arm or on another part of the body.

Choice E reason:

Performing range-of-motion exercises on the affected arm is not something to avoid, but rather something to do gradually and carefully. Range-of-motion exercises can help restore mobility and flexibility to the arm and prevent stiffness and contractures. The client should be instructed to start doing gentle exercises as soon as possible after surgery and to increase the intensity and duration as tolerated. The client may be referred to a physical therapist for additional guidance and support.

A. Hypothermia, bradycardia, and hypotension. B. Hyperthermia, tachycardia, and hypertension. C. Hypothermia, tachypnea, and hypertension. D. Hyperthermia, bradypnea, and hypotension.

Correct Answer is B

Explanation

Choice A reason:

Hypothermia, bradycardia, and hypotension are not signs of malignant hyperthermia, but rather signs of hypovolemia, shock, or anesthesia overdose. Malignant hyperthermia is a rare but life-threatening condition that occurs when a patient is exposed to certain anesthetic agents and develops a hypermetabolic response that leads to high fever, muscle rigidity, tachycardia, hypertension, acidosis, and rhabdomyolysis.

Choice B reason:

Hyperthermia, tachycardia, and hypertension are the classic signs of malignant hyperthermia. The patient may also experience increased carbon dioxide production, decreased oxygen saturation, dysrhythmias, cyanosis, muscle breakdown, and organ failure. The nurse should monitor the patient's vital signs, temperature, blood gases, electrolytes, and urine output closely and notify the anesthesia care provider immediately if malignant hyperthermia is suspected. The treatment involves stopping the anesthetic agent, administering 100% oxygen, cooling the patient with ice packs and cold intravenous fluids, and giving dantrolene sodium intravenously to relax the muscles.

Choice C reason:

Hypothermia, tachypnea, and hypertension are not consistent with malignant hyperthermia. Hypothermia may occur due to exposure to cold operating room environment or intravenous fluids. Tachypnea may be caused by pain, anxiety, hypoxia, or acidosis. Hypertension may be related to stress, pain, or sympathetic stimulation. These signs are not specific to malignant hyperthermia and do not indicate a hypermetabolic state.

Choice D reason:

Hyperthermia, bradypnea, and hypotension are not typical of malignant hyperthermia. Hyperthermia may occur due to infection, inflammation, or dehydration. Bradypnea may be a result of oversedation, opioid administration, or respiratory depression. Hypotension may be due to blood loss, dehydration, or vasodilation. These signs do not reflect a hypermetabolic state or muscle rigidity that are characteristic of malignant hyperthermia.

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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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