The nurse is planning care for client who is recovering from a total abdominal hysterectomy for uterine cancer. The nurse would include which intervention to decrease the risk of an embolic event?
Encourage the use of incentive spirometry
report 8/10 incisional pain
Assess popliteal pulses
Early ambulation
The Correct Answer is D
A. This option is primarily aimed at promoting lung expansion and preventing atelectasis (collapse of the lung). While it's an important post-operative intervention, it does not directly reduce the risk of embolic events related to venous thromboembolism.
B. Reporting significant pain (8/10) may indicate complications such as infection or improper healing, but it does not directly relate to reducing the risk of embolic events. While managing pain is important for recovery, simply reporting it does not contribute to preventing VTEs.
C. Assessing popliteal pulses is part of a thorough circulatory assessment, but it mainly focuses on blood flow to the lower extremities rather than preventing embolic events. It can help identify existing DVT but does not actively reduce the risk of embolism.
D. This statement is true and is the best choice for decreasing the risk of an embolic event. Early ambulation promotes venous return, improves circulation, and significantly lowers the risk of DVT and pulmonary embolism in post-operative patients. Encouraging patients to get out of bed and move around as soon as they are stable is a key nursing intervention in post-operative care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. One of the most common and concerning symptoms of uterine (endometrial) cancer is abnormal vaginal bleeding, particularly postmenopausal bleeding. Any bleeding after menopause is considered abnormal and can be an indicator of uterine cancer, warranting further investigation.
B. While a malodorous vaginal discharge can occur due to infections or other gynecological issues, it is not a primary symptom of uterine cancer. Uterine cancer more commonly presents with bleeding rather than discharge.
C. While some women with advanced uterine cancer may experience pelvic pain or pain during intercourse (dyspareunia), this symptom is not as characteristic or early in the disease process. It is more associated with conditions like endometriosis or pelvic inflammatory disease.
D. This is not a typical manifestation of uterine cancer. While vulvar swelling may be seen in cases of vulvar cancer or infections, it is not a common symptom associated with uterine cancer specifically. Symptoms related to uterine cancer primarily focus on abnormal bleeding.
Correct Answer is C
Explanation
A. This intervention can be appropriate since a very low platelet count increases the risk of bleeding, including gastrointestinal bleeding. However, this action alone does not directly address the immediate risks associated with the low platelet count.
B. While hydration is important for overall health, this intervention does not specifically address the risks associated with a low platelet count. Additionally, excessive fluid intake may not be appropriate for all patients, especially if there are underlying kidney issues or fluid restrictions.
C. Clients with AML and low platelet counts are at increased risk for infections and may develop febrile neutropenia. Monitoring temperature every four hours can help detect early signs of infection, allowing for timely intervention.
D. While maintaining oral hygiene is important, especially in patients undergoing chemotherapy, this intervention may not be the most critical action based on the acute concern of a very low platelet count. However, it is important to note that patients with low platelet counts may also experience bleeding from the gums, making gentle oral care essential.
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