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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
A) Increase of high-density lipoproteins: While higher levels of high-density lipoproteins (HDL) are generally associated with a lower risk of cardiovascular disease, enalapril is not primarily used to target lipid levels. Its main purpose is to manage blood pressure and reduce the risk of heart failure and renal complications, rather than specifically affecting HDL levels.
B) Decreased pain from intermittent claudication: Intermittent claudication is typically related to peripheral artery disease, which may not be directly improved by enalapril. While managing blood pressure can indirectly benefit circulation, enalapril is not indicated specifically for alleviating pain associated with claudication.
C) Decreased blood pressure: Enalapril is an ACE inhibitor used primarily to treat hypertension. A significant decrease in blood pressure is a direct therapeutic effect of the medication, indicating that it is effectively managing the client’s condition. Monitoring blood pressure helps assess the medication's efficacy in achieving the desired therapeutic outcome.
D) Decrease in low-density lipoproteins: Although reducing low-density lipoprotein (LDL) levels can benefit cardiovascular health, enalapril is not primarily prescribed for this purpose. Its effects on lipid levels are minimal compared to its role in lowering blood pressure and protecting renal function, making a decrease in LDL levels an irrelevant indicator of its therapeutic effect.
Correct Answer is A
Explanation
A. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on 2 or more separate occasions.": This statement accurately reflects the criteria for diagnosing hypertension. According to guidelines, a diagnosis is typically confirmed when blood pressure readings consistently exceed normal levels (usually defined as 130/80 mm Hg) on two or more separate visits.
B. "For confirmed diagnosis of hypertension, BP readings should be lower than normal on only one occasion.": This statement is incorrect. A single low reading does not confirm a diagnosis of hypertension. In fact, it contradicts the concept of hypertension, which involves consistently high readings.
C. "For confirmed diagnosis of hypertension, BP readings should be higher than normal on more than three separate occasions.": This statement is misleading. While multiple readings are often taken, the threshold for diagnosis is two or more elevated readings, not three.
D. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on only one occasion.": This statement is inaccurate, as a single elevated reading is not sufficient for diagnosis. Consistent elevations over multiple occasions are necessary for a confirmed diagnosis.