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 D
Explanation
A) Tachycardia: Propranolol is often used to manage tachycardia by reducing heart rate and controlling excessive adrenergic activity. Therefore, this diagnosis would not warrant clarification of the order; it is an appropriate use of the medication.
B) End-stage kidney failure: While caution is necessary when administering medications in clients with renal impairment, propranolol is primarily metabolized by the liver, and its use is not contraindicated in end-stage kidney failure. However, renal function can affect dosing, so monitoring would be important, but this diagnosis alone wouldn't require clarification.
C) Hypertension: Propranolol is commonly prescribed to manage hypertension, making this diagnosis a valid reason for the medication order. The use of propranolol in this context would not need clarification.
D) Asthma: Propranolol is a non-selective beta-blocker, which can cause bronchoconstriction and exacerbate asthma symptoms. This diagnosis would require the nurse to clarify the order, as beta-blockers are generally contraindicated in clients with asthma due to the risk of respiratory complications. If the client has reactive airway disease, an alternative medication should be considered.
Correct Answer is A
Explanation
A. "Diuretics are the first line therapy to control hypertension.": This statement is accurate. Thiazide diuretics are commonly recommended as first-line treatment for mild hypertension, as they help reduce blood volume and lower blood pressure effectively.
B. "Reaching your goal blood pressure will occur within 2 months.": While treatment can lead to improvements in blood pressure, the timeline for reaching target levels can vary significantly among individuals based on adherence to lifestyle changes and medication. It's important to communicate that achieving the goal may take longer than two months.
C. "Plan to add saturated fats to 10 percent of your daily calorie intake.": This recommendation is misleading. Guidelines generally suggest limiting saturated fats to less than 10 percent of total daily calories to promote heart health, not adding them.
D. "Limit your alcohol consumption to three drinks a day.": This statement is also inaccurate. For most adults, the recommendation is to limit alcohol to no more than two drinks per day for men and one drink per day for women to help manage blood pressure effectively.