A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?
Place 3 to 4 pillows under the client's knees when resting in bed.
Massage the client's posterior lower legs.
Have the client ambulate.
Apply warm, moist heat to the client's lower extremities.
The Correct Answer is C
A. Placing pillows under the client's knees may provide comfort but does not address the prevention of thromboembolic disease.
B. Massaging the client's posterior lower legs may increase the risk of dislodging a clot in clients with a history of thromboembolic disease.
C. Having the client ambulate helps prevent venous stasis and reduces the risk of thromboembolic events.
D. Applying warm, moist heat to the client's lower extremities may provide comfort but does not address the prevention of thromboembolic disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50"]
Explanation
To calculate the infusion rate for antibiotic X, the nurse needs to use the formula: gtt/min = (Volume x Drop factor) / Time
Plugging in the values from the question, we get:
gtt/min = (50 mL x 20 gtt/mL) / 20 min Simplifying, we get:
gtt/min = 1000 gtt / 20 min Dividing, we get:
gtt/min = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
Correct Answer is B
Explanation
A. The ball of the foot is not recommended for heelstick procedures.
B. The outer aspect of the heel is the preferred site. This area has fewer nerve endings and less risk of damaging the bone or cartilage.
C. The area below the fifth toe is not a standard site for a heelstick.
D. The walking surface of the heel should be avoided since it is prone to infection, more sensitive, and may interfere with walking.
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