A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?

"Why have you changed your mind about the surgery?"

"Your provider would not have scheduled the surgery unless you needed it."

"I will call your doctor and have him discuss your surgery with you."

"Bypass surgery must be very frightening for you."

Answer and Explanation

The Correct Answer is D

A. "Why have you changed your mind about the surgery?" Asking "why" may sound accusatory and could cause the client to feel defensive. It's more effective to use therapeutic communication techniques that encourage open expression of feelings.

B. "Your provider would not have scheduled the surgery unless you needed it."This response minimizes the client's concerns and implies that their feelings are not valid, which can hinder communication.

C. "I will call your doctor and have him discuss your surgery with you." While involving the provider is important, this response deflects the client's concerns without first addressing their feelings or providing support.

D. "Bypass surgery must be very frightening for you." This response uses a therapeutic communication technique by acknowledging the client’s emotions and opening the conversation for further exploration of their concerns.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Assist with ordered exercise as needed: Mobility and exercises such as ankle pumps help promote circulation and prevent venous stasis, reducing the risk of DVT.

B. Encourage fluids: Encouraging fluids helps prevent dehydration, which reduces blood viscosity and lowers the risk of clot formation.

C. Measure affected limb circumference: Measuring limb circumference is important for detecting early signs of DVT, such as swelling in the affected limb.

D. Massage calves and thighs: Massaging the legs is contraindicated in clients at risk for DVT as it can dislodge a clot, leading to a pulmonary embolism.

E. Apply compression stockings: Compression stockings promote venous return and reduce the risk of blood pooling in the lower extremities, thus preventing DVT.

A. Soft, pliable calf muscle B. Cool and clammy skin C. Dull, aching calf pain D. Temperature > 100 F

Correct Answer is C

Explanation

A. Soft, pliable calf muscle: A soft and pliable calf muscle is not indicative of a thrombus. Typically, a thrombus leads to swelling and firmness in the affected area.

B. Cool and clammy skin: Cool and clammy skin could indicate poor circulation, but it is not specific to a thrombus.

C. Dull, aching calf pain: Dull, aching calf pain is a key symptom of deep vein thrombosis (DVT) and should prompt further investigation.

D. Temperature > 100°F: A fever could indicate an infection but is not a classic sign of a thrombus.

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A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the care plan of a client who is postoperative and has an increased risk for deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan? (Select all that apply)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

Correct Answer is C

Explanation

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