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) "These tests will enable the provider to determine the heart structure and mobility of the heart valves." This statement is incorrect because cardiac enzyme tests, including troponin levels, do not assess heart structure or valve mobility. Imaging studies like echocardiograms are typically used for evaluating heart structure and function.
B) "Cardiac enzymes assist in diagnosing the presence of congestive heart failure." While cardiac enzymes can provide some information about heart function, they are not specifically used to diagnose congestive heart failure. The primary role of cardiac enzymes, particularly troponin, is in diagnosing myocardial injury, such as an acute myocardial infarction.
C) "Cardiac enzymes like troponin shows there has been damage to the heart tissues and muscle." This statement accurately reflects the purpose of measuring troponin levels. Troponin is a protein released into the bloodstream when heart muscle cells are damaged, making it a crucial biomarker for diagnosing an acute myocardial infarction.
D) "Cardiac enzymes will identify the exact location of the MI." This statement is misleading. While troponin levels can indicate that damage has occurred, they do not provide information about the specific location of the myocardial infarction. Other imaging techniques, such as an angiogram, are needed to determine the exact location of blockages or damage.
Correct Answer is D
Explanation
A) Blood pressure 102/76: While this blood pressure reading is on the lower side, it does not typically warrant withholding carvedilol unless the client exhibits symptoms of hypotension, such as dizziness or fainting. Carvedilol is an antihypertensive, but the reading itself is not critically low enough to necessitate holding the medication.
B) Temperature of 100.3 F: A mild fever at this temperature does not directly relate to carvedilol administration. It may indicate an underlying infection or inflammation, but it is not a contraindication for administering the medication. Monitoring the client’s temperature is important, but it does not require notifying the healthcare provider in this context.
C) Respiratory rate 10: A respiratory rate of 10 breaths per minute indicates bradypnea, which can be concerning. However, it is not the primary reason to withhold carvedilol unless the client shows significant respiratory distress. Monitoring is essential, but the decision to withhold the medication would depend on the overall clinical picture.
D) Heart rate of 49: A heart rate of 49 bpm is considered bradycardia and is a significant concern when administering carvedilol, a beta-blocker that can further decrease heart rate. It is essential to hold the medication and notify the healthcare provider, as this bradycardia could lead to potential adverse effects or complications. Monitoring the client's heart rate is crucial in managing their medication safely.