A nurse is planning postoperative care for a client following a total hip arthroplasty. What nursing interventions would help prevent venous thromboembolism for this client? (Select all that apply)
Early ambulation.
Fluid restriction.
Quadriceps-setting exercises.
Compression stockings/devices.
Anticoagulant drug therapy.
Correct Answer : A,C,D,E
Choice A reason: Early ambulation post-hip arthroplasty promotes venous blood flow, reducing stasis, a key factor in Virchow’s triad for thromboembolism. Muscle contractions enhance circulation, preventing clot formation in deep veins, significantly lowering the risk of pulmonary embolism.
Choice B reason: Fluid restriction does not prevent venous thromboembolism and may increase blood viscosity, promoting clot formation. Adequate hydration supports circulation, reducing stasis, making fluid restriction counterproductive for preventing thromboembolism in postoperative clients.
Choice C reason: Quadriceps-setting exercises activate muscle pumps in the legs, promoting venous return and reducing blood stasis. This mechanical action prevents clot formation in deep veins, making it an effective intervention to lower thromboembolism risk post-surgery.
Choice D reason: Compression stockings/devices apply external pressure, enhancing venous return and preventing blood pooling in the legs. This reduces stasis, a major risk factor for deep vein thrombosis, making them a standard preventive measure post-hip arthroplasty.
Choice E reason: Anticoagulants (e.g., heparin) inhibit clot formation by interfering with the coagulation cascade, reducing the risk of thromboembolism. They are critical post-hip arthroplasty, as surgery increases clotting risk due to endothelial damage and immobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Febrile seizures are not strictly tied to a specific temperature like 38.3°C (101°F) but rather to rapid temperature changes. A fixed threshold oversimplifies the trigger, as the rate of temperature rise is more critical than a single value.
Choice B reason: Anticonvulsants are not routinely used to prevent febrile seizures, as most are benign and self-limiting. Prophylactic medications like phenobarbital are reserved for complex cases, as they carry risks like sedation and do not address the fever’s cause.
Choice C reason: Febrile seizures, especially simple ones, rarely lead to epilepsy (risk <5%). They are typically benign, occurring in neurologically normal children aged 6 months to 5 years, triggered by fever, not indicative of chronic seizure disorders.
Choice D reason: Febrile seizures are triggered by a rapid rise in body temperature, often during the early phase of a fever. This rapid change lowers the seizure threshold in young children, causing neuronal hyperexcitability, leading to seizures, making this the correct explanation.
Correct Answer is A
Explanation
Choice A reason: Frequent neurovascular checks (pulse, sensation, movement) in Bryant’s traction, used for pediatric femur fractures, detect early signs of compartment syndrome or vascular compromise. This prevents complications like tissue ischemia or nerve damage, critical due to traction’s pressure on soft tissues.
Choice B reason: Tight bandages in Bryant’s traction can cause skin breakdown or impair circulation, increasing the risk of pressure ulcers or compartment syndrome. Bandages should be snug but not constrictive to maintain skin integrity and ensure proper traction function.
Choice C reason: Restraining a child from rolling over may prevent traction disruption but increases the risk of pressure ulcers and discomfort. Controlled movement within traction limits is allowed, and restraint does not directly address neurovascular or circulatory complications.
Choice D reason: The child’s buttocks should be slightly elevated in Bryant’s traction to maintain proper alignment and traction force. Resting on the bed negates the traction’s effect, risking bone misalignment and delayed healing, increasing complication risks.
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