The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?

Have client use the incentive spirometer every hour

Help client dangle legs off the side of the bed

Encourage the client to ambulate as soon as possible

Keep the client in bed with knees elevated

Limit the amount of fluid the client drinks

Answer and Explanation

The Correct Answer is B

A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.

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Correct Answer is C

Explanation

A. Curved prongs fitting the nasal passages correctly is appropriate practice for comfort and effective delivery.
B. Padding pressure areas on the skin is a best practice to prevent skin breakdown and is indicative of proper care.
C. An oxygen flow rate of 10 L/min is excessively high for a nasal cannula, which typically accommodates 1-6 L/min; this indicates a need for further education on proper flow rates.
D. Posting clear no smoking and no open flame signs is essential for safety in oxygen therapy, reflecting good practice.
E. Proper adjustment of cannula tubing under the neck is necessary to ensure a secure fit without causing discomfort.

A. 3+ B. 1+ C. 2+ D. +0 E. 4+

Correct Answer is B

Explanation

A. 3+ edema indicates moderate pitting (indentation depth of 5-7 mm and lasting 10-20 seconds).
B. 1+ edema is classified as slight pitting (indentation depth less than 2 mm that disappears rapidly, typically in less than 10 seconds), making this the correct documentation.
C. 2+ edema indicates moderate pitting (indentation depth of 3-4 mm that lasts up to 15 seconds).
D. +0 indicates no edema present at all.
E. 4+ edema indicates severe pitting (indentation depth of greater than 8 mm and lasting more than 20 seconds).

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The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates a need for more staff education about oxygen therapy?

Correct Answer is C

Explanation

How would the nurse document mild, slight pitting edema of the ankles, where there can be no perceptible swelling seen, the indentation depth will be less than 2mm, and the indentation will disappear in less than 10 seconds?

Correct Answer is B

Explanation

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