A nurse is caring for an elderly client recovering after a dermatologic surgery. The client reported increased redness and itching around the surgical site and the area appears slightly warm to touch.
Which nursing actions are appropriate in monitoring and caring for a client with altered tissue integrity?

Choice A rationale

Limiting fluid intake is detrimental to a post-surgical patient as it increases blood viscosity and promotes stasis. Dehydration can lead to hemoconcentration, which is a significant risk factor for the formation of thrombi in the deep veins of the legs. Maintaining adequate hydration is essential to ensure smooth blood flow and to decrease the concentration of clotting factors. Nurses should encourage fluids rather than restrict them to help maintain optimal hemodynamic stability and venous return.

Choice B rationale

Early ambulation is the gold standard for preventing deep vein thrombosis after orthopedic surgery. Physical movement activates the skeletal muscle pump in the calves, which compresses the deep veins and propels blood back toward the heart. This prevents venous stasis, one of the components of Virchow's triad. By getting the patient out of bed early, the nurse reduces the time blood spends pooling in the lower extremities, significantly lowering the probability of clot formation.

Choice C rationale

While frequent blood pressure monitoring is necessary to assess the patient's general cardiovascular status and recovery from anesthesia, it does not directly prevent the formation of a deep vein thrombosis. Blood pressure readings reflect systemic vascular resistance and cardiac output but do not address the localized venous stasis occurring in the lower limbs. While a normal blood pressure of 120 over 80 mmHg is ideal, it is not a specific preventative measure for venous thromboembolism.

Choice D rationale

Application of ice packs is primarily used to reduce localized edema and provide analgesia at the surgical site. While it helps manage inflammation, it does not prevent the systemic or regional conditions that lead to deep vein thrombosis. In some cases, extreme cold might cause localized vasoconstriction, which could theoretically slow blood flow if applied incorrectly. The focus for DVT prevention must remain on promoting venous return through mechanical means like ambulation or compression devices.

Choice A rationale

The skeletal framework provides a rigid internal structure that supports soft tissues and provides attachment points for tendons of most skeletal muscles. This architectural integrity ensures that the body maintains its distinctive human shape and form against the constant pull of gravity. Without this bony scaffolding, the body would lack the necessary tension and leverage required for upright posture and various locomotor activities in space.

Choice B rationale

Reflexive responses to injuries are primarily a function of the nervous system, specifically involving the sensory neurons, interneurons in the spinal cord, and motor neurons. While the musculoskeletal system executes the physical movement of the reflex, the coordination and initiation of the response are neural processes rather than inherent musculoskeletal functions. The musculoskeletal system acts as the effector organ that carries out the command sent by the peripheral nervous system.

Choice C rationale

Hematopoiesis is the vital process of blood cell formation that occurs within the red bone marrow found in the epiphyses of long bones and within flat bones. Red marrow contains pluripotent stem cells that differentiate into erythrocytes, leukocytes, and thrombocytes. While yellow marrow consists mainly of adipose cells for energy storage, it can revert to red marrow during periods of severe chronic anemia or significant blood loss to increase blood cell production.

Choice D rationale

The skeletal system serves as a biological shield for internal delicate structures and vital organs. The cranium encloses the brain, the vertebral column protects the spinal cord, and the rib cage safeguards the heart and lungs from external mechanical trauma. This protective mechanism is essential for the survival of the organism, as it prevents direct injury to the central nervous system and the thoracic viscera during daily physical impacts.

Choice E rationale

The musculoskeletal system is a primary reservoir for minerals such as calcium and phosphorus, but it does not produce potassium. Potassium is an intracellular cation primarily regulated by the kidneys and adrenal hormones like aldosterone through renal excretion and reabsorption processes. While bones store approximately 99 percent of the body's calcium, the concentration of potassium in the body is maintained through dietary intake and sophisticated renal filtration and secretion mechanisms.