A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?
Ambulating soon after surgery
Flexing her ankles
Massaging her legs
Elevating her feet
The Correct Answer is C
A) Ambulating soon after surgery: Early ambulation is encouraged for postoperative clients to promote circulation and reduce the risk of venous thromboembolism (VTE). Mobilizing helps prevent stasis of blood in the veins, making this an appropriate action rather than an unsafe one.
B) Flexing her ankles: Ankle flexion exercises can help improve venous return and circulation in the lower extremities. This action is generally recommended to prevent VTE, making it a safe and beneficial practice for postoperative clients.
C) Massaging her legs: Massaging the legs is considered unsafe for a client at risk for VTE. This action can dislodge a thrombus (blood clot) if one is present, leading to potential complications such as pulmonary embolism. Therefore, the nurse should instruct the client to avoid leg massages.
D) Elevating her feet: Elevating the feet is a recommended practice to promote venous return and reduce swelling in postoperative clients. This action can help prevent VTE and is generally considered safe and beneficial.
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Correct Answer is ["B","E"]
Explanation
A) Provide discharge instructions for a client who has a new skin graft: This task should not be delegated to an assistive personnel (AP) as it requires clinical judgment and knowledge about the specific care needs associated with a new skin graft. Discharge instructions must be provided by a qualified nurse.
B) Weigh a client who is on fluid restriction: This task can be delegated to an AP. Weighing a client is a straightforward procedure that does not require nursing judgment and is within the scope of practice for an AP.
C) Check a blood product with another nurse prior to administration: This task must be performed by a licensed nurse to ensure patient safety and compliance with protocols. Checking blood products requires knowledge of the client's specific needs and potential reactions.
D) Perform an admission assessment on a client: Admission assessments require nursing expertise and critical thinking. This task cannot be delegated to an AP, as it involves evaluating the client's condition and creating a care plan based on the assessment findings.
E) Ambulate an older adult client who has hypertension: This task can be delegated to an AP, provided the client is stable and there are no other complications. Assisting with ambulation is within the scope of practice for an AP, and it can help promote mobility and independence for the client.
Correct Answer is A
Explanation
A. "Diuretics are the first line therapy to control hypertension.": This statement is accurate. Thiazide diuretics are commonly recommended as first-line treatment for mild hypertension, as they help reduce blood volume and lower blood pressure effectively.
B. "Reaching your goal blood pressure will occur within 2 months.": While treatment can lead to improvements in blood pressure, the timeline for reaching target levels can vary significantly among individuals based on adherence to lifestyle changes and medication. It's important to communicate that achieving the goal may take longer than two months.
C. "Plan to add saturated fats to 10 percent of your daily calorie intake.": This recommendation is misleading. Guidelines generally suggest limiting saturated fats to less than 10 percent of total daily calories to promote heart health, not adding them.
D. "Limit your alcohol consumption to three drinks a day.": This statement is also inaccurate. For most adults, the recommendation is to limit alcohol to no more than two drinks per day for men and one drink per day for women to help manage blood pressure effectively.