The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the client takes oral contraceptives and recognizes that this increases the client's risk for post-operative complications. What intervention should the nurse include in the postoperative plan of care?

Dependent positioning of the client's extremities when at rest

Doppler ultrasound of peripheral circulation twice daily

Early ambulation and leg exercises

Cessation of oral contraceptives until 3 weeks postoperative

Answer and Explanation

The Correct Answer is C

A. Dependent positioning can increase the risk of venous pooling and thrombosis.
B. Doppler ultrasound may be used if there is a suspicion of thrombosis but is not a standard preventative intervention.
C. Early ambulation and leg exercises promote circulation and reduce the risk of deep vein thrombosis, which is increased by oral contraceptive use.
D. Stopping oral contraceptives pre- or postoperatively is a physician’s decision, not a nursing intervention.

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Correct Answer is D

Explanation

A. This is an inaccurate explanation and may confuse the client.
B. Both medications are used together temporarily for proper anticoagulation management.
C. The simultaneous use is intentional and part of standard treatment, not a mistake.
D. Warfarin has a delayed onset and takes several days to become effective. Heparin is continued during this period to provide immediate anticoagulation. Once warfarin reaches therapeutic levels, heparin is discontinued.

A. Place the client in a supine position postoperatively B. Instruct the client to lift over 4.5 kg (10 lb) C. Encourage ambulation once fully awake D. Offer the client ice cream postoperatively

Correct Answer is C

Explanation

A. The client should be positioned to optimize comfort and respiratory function, often semi-Fowler’s, not strictly supine.
B. Clients should avoid lifting heavy objects (over 10 lb) to prevent strain on surgical sites.
C. Early ambulation promotes circulation, prevents complications, and is encouraged once the client is alert and stable.
D. Ice cream is typically not recommended immediately postoperatively due to nausea risk and dietary restrictions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action postoperatively?

Correct Answer is C

Explanation

The nurse caring for a client post-colon resection assesses the client on the second postoperative day. The nasogastric be remains patent and is draining moderate amounts of greenish fluid. Which assessment finding would suggest that the client's potassium level is too low?

Four hours after surgery, the blood glucose level of a client who has type 1 diabetes is elevated. Which of the following actions would the nurse expect?

A nurse provides preoperative teaching by demonstrating diaphragmatic breathing to a client scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?

Which assessment finding would alert the nurse to the possibility of worsening hyponatremia?

A nurse observes mild hand tremors in a client who has diabetes mellitus. What actions should the nurse take after obtaining a glucose meter reading of 60 mg/dL?

A nurse is caring for a client who has uncontrolled type 1 diabetes mellitus. Which of the following findings should the nurse expect?

The nurse cares for a client receiving Enoxaparin subcutaneously to prevent deep vein thrombosis (DVT). Which assessment findings should be reported to the health care provider immediately?