A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?

Keep the client's knees in a flexed position while they are in bed.

Massage the client's legs every 4 hr while they are awake.

Encourage the client to perform circumduction of the feet.

Limit the client's fluid intake to 2,000 mL daily.

Answer and Explanation

The Correct Answer is C

A)   Keeping the client's knees in a flexed position, is incorrect because prolonged immobility and knee flexion can increase the risk of VTE by impeding venous return.
B)   Massaging the client's legs, is not recommended as it may dislodge a potential clot that has formed, leading to a thromboembolic event.
C)   This exercise can help promote blood circulation and prevent clot formation without exerting excessive pressure on the surgical site.
D)   Adequate hydration is essential for preventing blood clots; dehydration can lead to hemoconcentration and increased risk of thrombosis.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Explanation

A)   An increase in oxygen saturation to 96% at a reduced oxygen flow rate indicates potential improvement in respiratory function, which can be a positive sign of recovery from a UTI.
B)   Disorientation to person, place, and time suggests a potential worsening of the condition, as UTIs can cause confusion, especially in older adults and those with dementia.
C)   A drop in blood pressure to 100/50 mm Hg could indicate potential worsening, as it may suggest dehydration or sepsis, both of which can complicate a UTI.
D)   A decrease in hematocrit (Hct) to 45% is within the normal range and could indicate an improvement if previously elevated due to dehydration.
E)   Pink-tinged urine may indicate the presence of blood, a sign of potential worsening, as it could suggest a more severe infection or other complications.
F)   A butterfly rash is not typically associated with a UTI and may be unrelated to the current diagnosis; in this scenario it is related to the patient’s history of systemic lupus erythematosus.

A. A B. B C. C

Correct Answer is {"xRanges":[413.765625,473.765625],"yRanges":[424.609375,484.609375]}

Explanation

A transverse colon colostomy is typically placed in the upper abdomen, either in the middle or toward the right side of the body. In the above scenario the best location will be B which is located along the path of the transverse colon. Point A would be suitable for an ileostomy while point B will be suitable for a sigmoid colostomy.

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A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Explanation

Correct Answer is {"xRanges":[413.765625,473.765625],"yRanges":[424.609375,484.609375]}

Explanation

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