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The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?

Have client use the incentive spirometer every hour

Help client dangle legs off the side of the bed

Encourage the client to ambulate as soon as possible

Keep the client in bed with knees elevated

Limit the amount of fluid the client drinks

Answer and Explanation

The Correct Answer is B

A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.

B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.

C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.

D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.

E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.

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A. "I would palpate, inspect, percuss, and the auscultate.” B. "I would percuss, palpate, auscultate, and then inspect.” C. "I would auscultate, inspect, percuss, and then palpate." D. "I would inspect, auscultate, palpate, and then percuss." E. "I would inspect, palpate, percuss, then auscultate.”

Correct Answer is E

Explanation

A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.

B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.

C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.

D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.

E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.

A. A client demonstrates how to inject insulin into the abdomen B. A client attends a course on exercise techniques C. A client watches the nurse apply a dressing D. A client lists food choices that are considered part of a healthy diet E. A client nods when told how to take the blood pressure medication

Correct Answer is ["A","D"]

Explanation

A. Demonstrating an insulin injection shows hands-on learning and mastery of the skill.

B. Attending a course does not confirm comprehension or skill.

C. Watching a nurse apply a dressing does not guarantee learning; active participation is necessary.

D. Listing healthy food choices indicates understanding of dietary education.

E. Nodding does not confirm learning; it may only indicate acknowledgment.

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The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?

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Correct Answer is E

Explanation

Correct Answer is ["A","D"]

Explanation

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Take full exam for free The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?

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Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?

Correct Answer is E

Explanation

Which of the following scenarios gives the most absolute confirmation client learning has taken place? Select all that apply.

Correct Answer is ["A","D"]

Explanation

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The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?