Which action should the nurse implement to help prevent thrombus formation in postsurgical patients?
Maintain complete bed rest
Place light wrapping on the legs and waist
Encourage early ambulation
Put pillows under the knees
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Chronic alcohol abuse may cause hypomagnesemia, which can mimic hypocalcemia symptoms, but a positive Chvostek sign is specific to low calcium. Alcoholism alone is less likely to cause this sign without concurrent hypocalcemia, making this choice incorrect.
Choice B reason: Osteoporosis in a 75-year-old involves bone density loss but does not typically cause hypocalcemia or a positive Chvostek sign. Calcium levels are usually normal unless other conditions exist, making this choice incorrect for the expected finding.
Choice C reason: Acute hyperparathyroidism can lead to hypocalcemia after parathyroidectomy or in secondary complications, causing a positive Chvostek sign (facial twitching when tapping the facial nerve). Low calcium triggers this neuromuscular response, making this the correct choice.
Choice D reason: Severe burns cause fluid shifts and potential electrolyte imbalances, but hypocalcemia is not a primary feature. A positive Chvostek sign is less likely without specific calcium depletion, making this choice incorrect for the expected finding.
Correct Answer is C
Explanation
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.
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