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 ["A","D","F"]
Explanation
A) Smoking cessation: Quitting smoking is one of the most critical interventions for clients with peripheral arterial disease (PAD). Smoking contributes to vascular damage and worsens arterial circulation, so cessation can significantly slow disease progression and improve overall cardiovascular health.
B) Wear compression stockings: While compression stockings may be helpful for venous conditions, they are generally not recommended for clients with PAD. In fact, they can impair arterial flow, so this intervention should not be included in the teaching plan.
C) Use a heating pad directly on the legs: Using a heating pad directly on the legs is unsafe for clients with PAD, as it can lead to burns or injuries due to impaired sensation in the extremities. Additionally, excessive heat can exacerbate circulation issues.
D) Exercising will help increase circulation: Regular exercise is beneficial for clients with PAD. Supervised exercise programs, such as walking, can improve circulation and enhance functional capacity, helping to manage symptoms and slow disease progression.
E) Soak feet in hot water daily: Soaking feet in hot water can pose risks, particularly for individuals with PAD, as they may have reduced sensation and are at higher risk for burns or injuries. This practice should not be recommended.
F) Decrease saturated fats in daily diet: Reducing saturated fats in the diet can help improve overall cardiovascular health and lower cholesterol levels, which is beneficial for clients with PAD. A heart-healthy diet can help limit disease progression and improve circulation.
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.