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

Explanation

A. The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B. Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C. Administering corticosteroids is not indicated based on the client's symptoms and situation.
D. Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.

A. "The elastic bandage will prevent a postoperative wound infection." B. "The elastic bandage will prevent excessive edema." C. "The elastic bandage will keep you from seeing the surgical site." D. "The elastic bandage will keep the sutures from loosening."

Correct Answer is B

Explanation

A. While wound infection prevention is important, the elastic bandage primarily addresses edema control.
B. Maintaining an elastic bandage around the residual limb helps to compress soft tissues and minimize edema, promoting healing and aiding in the shaping of the residual limb for future prosthesis fitting.
C. The purpose of the elastic bandage is not related to preventing the client from seeing the surgical site.
D. The elastic bandage is not primarily used to secure sutures; its main purpose is edema control.

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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

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

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