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?
Encourage increased fluid intake
Keep the affected knee flexed
Promote bed rest for 5 days
Massage the patient’s calf on the affected side .
None
None
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Naloxone does not have any direct effect on respiratory secretions. It works by binding to opioid receptors in the brain and reversing the effects of opioids, such as respiratory depression.
While opioids can cause a decrease in respiratory secretions, this is not the primary reason for administering naloxone.
It is important to note that naloxone can actually worsen respiratory secretions in some patients, particularly those with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
Choice B rationale:
Naloxone is a medication that is specifically designed to block the effects of opioids on the central nervous system (CNS).
It is a competitive antagonist, which means that it binds to opioid receptors in the brain and prevents opioids from binding to those receptors.
This can reverse the effects of opioids, such as respiratory depression, sedation, and hypotension.
Naloxone is often used to treat opioid overdose, but it can also be used to prevent opioid-induced respiratory depression in patients who are receiving opioids for pain relief.
Choice C rationale:
Naloxone is not effective in treating nausea.
In fact, it can actually worsen nausea in some patients.
This is because naloxone can block the effects of opioids in the brain, and opioids can sometimes have a nausea-relieving effect.
Choice D rationale:
Naloxone is not effective in treating urinary retention.
Urinary retention is a common side effect of opioids, but it is not caused by the effects of opioids on the CNS. Urinary retention is typically caused by the effects of opioids on the bladder muscles.
Correct Answer is A
Explanation
This question addresses HIPAA privacy regulations and professional ethics regarding patient confidentiality. The nurse must identify the correct procedural response to unauthorized inquiries, ensuring that protected health information is not disclosed to staff members who are not involved in the patient's direct care.
Choice A rationale: Referring inquiries to the nursing supervisor is the correct professional action when dealing with potentially inappropriate requests for information. The supervisor ensures that facility policies and privacy regulations are upheld, preventing unauthorized disclosure of protected health information to peers.
Choice B rationale: Transferring calls directly to the patient room violates the patient's privacy and right to confidentiality. The nurse cannot determine if the caller is authorized to receive information, and allowing direct access may expose the patient to unwanted contact or information breaches.
Choice C rationale: Acknowledging that a specific individual is a patient on the unit is a breach of confidentiality under HIPAA. Information regarding a patient's presence or location in a facility is protected, and confirming this status to unauthorized personnel is strictly prohibited.
Choice D rationale: Contacting the provider is unnecessary and inappropriate for managing calls from other staff members. The nurse has a duty to protect patient privacy personally and should not shift the burden of screening these unauthorized inquiries to the healthcare provider.
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