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
Explanation
A. Within the expected reference range: While a blood pressure of 130/82 mm Hg is close to normal, it is not considered fully within the expected reference range. The normal range is typically defined as less than 120/80 mm Hg.
B. Elevated: The reading of 130/82 mm Hg falls into the "elevated" category, which is defined as systolic blood pressure between 120-129 mm Hg and diastolic pressure less than 80 mm Hg. This indicates that while the client is not hypertensive, they are at increased risk for developing hypertension in the future.
C. Stage 2 hypertension: This category is defined by a systolic reading of 140 mm Hg or higher, or a diastolic reading of 90 mm Hg or higher. The client’s reading does not meet these criteria, so this option is not applicable.
D. Stage 1 hypertension: Stage 1 hypertension is characterized by systolic readings between 130-139 mm Hg and diastolic readings between 80-89 mm Hg. Although the systolic reading is in the Stage 1 range, the diastolic reading of 82 mm Hg places the overall reading in the "elevated" category, rather than Stage 1 hypertension.
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.