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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.

A. "The bright light in this room is really bothering me.”. B. "It's hard to see with a patch on one eye. I'm afraid of falling.”. C. "I need something for the pain in my eye. I can't stand it.”. D. "My eye really itches, but I'm trying not to rub it.”.

Correct Answer is C

Explanation

Choice A rationale:
Sensitivity to light is a common postoperative symptom after cataract surgery.
Choice B rationale:
Difficulty with depth perception is expected when one eye is patched.
Choice C rationale:
Severe pain is not a normal postoperative symptom and should be reported to the provider.
Choice D rationale:
Itching is a common postoperative symptom after cataract surgery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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