A nurse is caring for a patient who is postoperative following a total knee replacement. What action should the nurse take to prevent deep vein thrombophlebitis?

 

The correct answer is Choice A.

Choice A rationale: Encouraging increased fluid intake helps maintain blood volume and reduces viscosity, promoting circulation and lowering the risk of venous stasis and clot formation postoperatively.

Choice B rationale: Keeping the affected knee flexed impairs venous return and increases stasis, elevating the risk of thrombosis. Proper positioning with extension promotes circulation and reduces clot risk.

Choice C rationale: Prolonged bed rest contributes to immobility-induced venous stasis, a major risk factor for DVT. Early ambulation and leg exercises are essential to prevent thromboembolic events.

Choice D rationale: Massaging the calf of a postoperative patient is contraindicated due to the risk of dislodging a thrombus, potentially leading to a life-threatening pulmonary embolism.

The correct answer is Choice A: Refer questions to the nursing supervisor.

Choice A rationale: By referring inquiries from other nurses to the nursing supervisor, the nurse maintains patient privacy and upholds healthcare privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA). These regulations mandate that patient information should only be disclosed on a need-to-know basis. Referring questions to the nursing supervisor ensures that any information released is managed through the appropriate channels and protects the patient's confidentiality.

Choice B rationale: Transferring calls directly to the patient's room could infringe on their privacy and disrupt their care or rest. It is not the nurse's role to decide if the patient should be disturbed, and doing so may potentially compromise patient care and satisfaction.

Choice C rationale: Acknowledging that the person is a patient on the unit can violate confidentiality rules, as it confirms the individual's presence in the hospital and could lead to speculation about their condition. Nurses must maintain patient privacy by refraining from sharing any information, even if it seems harmless.

Choice D rationale: Contacting the patient's provider does not directly address the issue of handling inquiries from other nurses and could breach confidentiality if the provider discloses information without the patient's consent. Additionally, the provider may not be immediately available, which would delay addressing the inquiries and potentially expose the patient's privacy further.