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 C
Explanation
A) Ventricular tachycardia: Ventricular tachycardia is characterized by a rapid heart rate exceeding 100 bpm, typically arising from abnormal ventricular activity. In this case, the heart rate is 59 bpm, which does not support this interpretation. Additionally, ventricular tachycardia usually presents with wide QRS complexes and no discernible P waves, neither of which is true in this scenario.
B) Sinus tachycardia: Sinus tachycardia is defined by a heart rate exceeding 100 bpm originating from the sinoatrial (SA) node, with a regular rhythm and normal P waves. The heart rate of 59 bpm in this client is too low for a diagnosis of sinus tachycardia, making this option incorrect.
C) Sinus bradycardia: Sinus bradycardia occurs when the heart rate is less than 60 bpm, with a regular rhythm and a normal PR interval and QRS duration. The provided data shows a heart rate of 59 bpm, a regular rhythm, one P wave for every QRS complex, a PR interval of 0.20 seconds, and a QRS duration of 0.10 seconds, which aligns perfectly with the criteria for sinus bradycardia.
D) Normal sinus rhythm: Normal sinus rhythm typically presents with a heart rate of 60-100 bpm, a regular rhythm, and appropriate P waves for each QRS complex. Given the heart rate of 59 bpm, this does not meet the criteria for normal sinus rhythm, as it falls below the acceptable range.
Correct Answer is ["A","C","D"]
Explanation
A) Furosemide: This is a loop diuretic that can lead to dehydration and electrolyte imbalances, both of which can contribute to orthostatic hypotension. The medication's diuretic effect can cause a significant drop in blood volume, increasing the risk of low blood pressure upon standing.
B) Simvastatin: This medication is used to lower cholesterol levels and is not associated with orthostatic hypotension. It does not have a direct impact on blood pressure or volume.
C) Losartan: As an angiotensin II receptor blocker (ARB), losartan is used to treat hypertension. It can cause vasodilation and may lead to orthostatic hypotension, particularly in elderly clients or those who are volume-depleted.
D) Nifedipine: This calcium channel blocker is used to treat hypertension and can cause vasodilation. It may lead to orthostatic hypotension as well, especially during dose adjustments or if the client is dehydrated.
E) Clopidogrel: This antiplatelet medication is used to prevent blood clots and does not directly cause orthostatic hypotension. Its primary action is to inhibit platelet aggregation, not to affect blood pressure.