In preparation for cardiac surgery, a patient was taught about measures to prevent venous thromboembolism.
Which statement indicates that the patient clearly understood this education?
I’ll make sure that I don’t cross my legs when I’m resting in bed.
I’ll keep pillows under my knees to help my blood circulate better.
I’ll put on those compression stockings if I get pain in my calves.
I’ll try to stay in bed for the first few days to allow myself to heal.
I’ll try to stay in bed for the first few days to allow myself to heal.
The Correct Answer is A
Choice A rationale:
Venous thromboembolism (VTE) is a blood clot that forms in a vein, usually in the legs. It can be a serious condition, as the clot can break loose and travel to the lungs, causing a pulmonary embolism (PE).
Crossing the legs at the knees can impede blood flow in the veins of the legs, increasing the risk of VTE. This is because it compresses the veins, slowing the flow of blood and making it more likely for clots to form.
The patient's statement that they will make sure not to cross their legs when resting in bed demonstrates that they understand this important risk factor for VTE and are taking steps to prevent it.
Choice B rationale:
While keeping pillows under the knees can help to improve circulation, it is not a specific measure to prevent VTE. It is more important to avoid crossing the legs and to engage in regular movement and activity to promote blood flow.
Choice C rationale:
Compression stockings can help to reduce the risk of VTE by compressing the veins in the legs and promoting blood flow. However, they should be worn as instructed by a healthcare professional, and not only if the patient experiences pain in their calves. Pain in the calves can be a symptom of VTE, so it is important to seek medical attention if it occurs.
Choice D rationale:
Bed rest is actually a risk factor for VTE, as it can lead to decreased blood flow in the legs. It is important to get up and move around as soon as possible after surgery, even if it is just for short periods of time. This will help to promote blood flow and reduce the risk of VTE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
B-type natriuretic peptide (BNP) is a hormone produced primarily by the ventricles of the heart in response to stretching of the heart muscle fibers. It plays a crucial role in regulating blood volume and pressure by promoting the excretion of sodium and water by the kidneys. Elevated levels of BNP in the blood are strongly suggestive of heart failure, as the heart muscle is working harder to pump blood, leading to increased BNP production.
Key points supporting A as the correct answer:
BNP is a highly sensitive and specific marker for heart failure. Studies have demonstrated its accuracy in diagnosing heart failure, even in early stages when symptoms may be subtle.
The patient's clinical presentation aligns with heart failure. Vital fatigue and shortness of breath are both classic symptoms of heart failure, resulting from the heart's inability to meet the body's demands for oxygenated blood.
Other choices are less likely based on the information provided. Pleurisy (inflammation of the lining of the lungs), cardiomyopathy (disease of the heart muscle), and valve dysfunction can all cause shortness of breath, but they would not typically lead to elevated BNP levels unless heart failure is also present.
Additional considerations:
BNP levels can be influenced by factors other than heart failure, such as age, kidney function, and certain medications. However, in the context of a patient with typical heart failure symptoms, an elevated BNP level strongly supports the diagnosis.
BNP testing is often used to guide treatment decisions in patients with heart failure. Serial BNP measurements can help assess the effectiveness of therapy and monitor for disease progression.
Correct Answer is B
Explanation
correct answer is Choice B.
Choice B rationale:
Orthostatic hypotension is a significant drop in blood pressure that occurs when a person stands up from a lying or sitting position. It's characterized by a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing.
The client's assessment data clearly demonstrates orthostatic hypotension, with a systolic blood pressure drop of 23 mmHg and a diastolic drop of 13 mmHg upon standing.
Orthostatic hypotension is a major risk factor for falls, especially in older adults. This is because the sudden decrease in blood pressure can lead to lightheadedness, dizziness, blurred vision, weakness, and even fainting.
Falls in older adults can result in serious injuries, such as fractures, head trauma, and even death. Therefore, it's crucial to identify and address orthostatic hypotension to prevent falls and their associated complications.
Rationales for other choices:
Choice A: Ineffective breathing pattern is not directly related to orthostatic hypotension. While hypotension can cause shortness of breath in some cases, it's not the primary concern in this scenario.
Choice C: Ineffective role performance can be a consequence of frequent falls, but it's not the most immediate or pressing nursing diagnosis in this case.
Choice D: Risk for imbalanced fluid balance is a potential concern in some cases of orthostatic hypotension, but it's not the most likely diagnosis based on the client's assessment data.
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