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.
Massaging her legs.
Flexing her ankles.
Elevating her feet.
The Correct Answer is B
Choice A rationale:
Ambulating soon after surgery is actually encouraged as it promotes blood flow and reduces the risk of VTE.
Choice B rationale:
Massaging the legs can dislodge a clot if one has formed, leading to a VTE.
Choice C rationale:
Flexing the ankles promotes blood flow and reduces the risk of VTE.
Choice D rationale:
Elevating the feet can reduce swelling and promote venous return, reducing the risk of VTE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Basal cell carcinoma often appears as a raised, flesh-colored lesion with pearly, white borders. It is the most common type of skin cancer.
Choice B rationale:
Actinic keratosis is a precancerous skin condition that can lead to squamous cell carcinoma if left untreated. It typically presents as dry, scaly patches or spots.
Choice C rationale:
Squamous cell carcinoma often appears as a firm, red nodule or a flat lesion with a scaly, crusted surface.
Choice D rationale:
Malignant melanoma is a more serious type of skin cancer that can develop anywhere on the body. It often appears as a new, irregular, or changing mole.
Correct Answer is B
Explanation
Choice A rationale:
Turning the client’s head to the side is important to prevent aspiration, but it should be done after documenting the time the seizure began.
Choice B rationale:
The first action when a client begins having a tonic-clonic seizure is to document the time the seizure began. This helps in determining the duration of the seizure, which is critical information for the healthcare team.
Choice C rationale:
Loosening the clothing around the client’s waist is important for the client’s comfort and safety during a seizure, but it should be done after documenting the time the seizure began.
Choice D rationale:
Checking the client’s motor strength is not the first action to take when a client begins having a tonic-clonic seizure.
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