The nurse is assessing a patient with obstructive sleep apnea. Which assessment is the priority?

Choice A reason: Black, tarry stool while taking ferrous sulfate may indicate gastrointestinal bleeding, a serious condition, rather than a normal side effect (greenish-black stool). This requires further questioning to rule out hemorrhage, making it the priority.

Choice B reason: Dizziness upon standing suggests orthostatic hypotension, a common issue that warrants monitoring but is less urgent than potential bleeding. It requires clarification but is not as critical as black stool.

Choice C reason: Taking medication with orange juice is generally safe, though it may affect absorption of some drugs. This is less concerning than black stool, which could indicate bleeding, making it a lower priority.

Choice D reason: Skipping a dose due to feeling fine indicates non-compliance, which needs education but is not immediately life-threatening. Black stool suggesting bleeding is more urgent, making this less critical for questioning.

Choice A reason: Complete bed rest increases stasis, a risk factor for thrombus formation per Virchow’s triad. Immobility slows venous return, promoting clot development, making this choice counterproductive and incorrect for preventing postoperative thrombi.

Choice B reason: Light wrapping may provide comfort but does not effectively prevent thrombus formation. Compression stockings are preferred for venous return, and wrapping alone is insufficient, making this choice less effective than ambulation.

Choice C reason: Early ambulation promotes venous return, reducing stasis and preventing thrombus formation in postsurgical patients. It enhances circulation, countering Virchow’s triad, and is a standard intervention, making this the correct action to implement.

Choice D reason: Pillows under the knees cause venous pooling by flexing joints, increasing thrombus risk. This contradicts measures to enhance circulation, such as ambulation, making it an incorrect choice for thrombus prevention.