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 D

Explanation

A. A pulse of 60 is low but does not necessarily indicate a need to stop suctioning if the patient remains stable otherwise.
B. A pulse of 90 is within normal limits and does not require stopping suctioning.
C. An oxygen saturation of 92% is slightly low but still acceptable; suctioning can continue if the client is stable.
D. An oxygen saturation of 89% is below the acceptable threshold and indicates hypoxia, prompting the nurse to stop suctioning immediately to avoid further compromising the client's respiratory status.
E. A blood pressure of 130/80 is within normal limits and does not warrant cessation of suctioning.

A. Considered normal part of aging B. Can be non-pathologic C. Heard just after S2 D. Caused by a dilated (more complaint) ventricle E. An expected finding in children

Correct Answer is ["A","B"]

Explanation

A. S4 is often considered a normal finding in older adults due to decreased ventricular compliance.
B. While it can be non-pathologic, it is more commonly associated with underlying conditions such as hypertension or heart failure.
C. The statement about being heard just after S2 is incorrect; S4 can be heard in various populations, particularly older adults.
D. An S4 sound is associated with a stiff or hypertrophied ventricle, not a dilated ventricle.
E. An S4 sound is not typically an expected finding in children; it is more common in older adults.

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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

A nurse is preparing to suction a client. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?

Correct Answer is D

Explanation

When performing a cardiovascular assessment, what would the nurse understand about an S4 heart sound?

Correct Answer is ["A","B"]

Explanation

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