The nurse is caring for a client receiving chemotherapy for acute leukemia. The client reports chills and weakness.
Assessment findings include a temperature of 101 F (38.3 C), heart rate 142 beats per minute, blood pressure 80/40 mm Hg, respiratory rate 32 breaths per minute, and O2 saturation 94 Which interpretation by the nurse is most accurate?

Postoperative care focuses on mitigating risks associated with anesthesia and immobility. This question addresses the prevention of atelectasis and pneumonia by applying knowledge of respiratory mechanics, alveolar expansion, and nursing interventions designed to optimize lung volumes and gas exchange.

Choice A rationale

Incentive spirometry promotes deep breathing and lung expansion, preventing alveolar collapse or atelectasis common after surgery. It encourages sustained maximal inspiration, which increases surfactant production and improves oxygenation, maintaining a normal oxygen saturation of 95 to 100 percent.

Choice B rationale

Range-of-motion exercises primarily prevent musculoskeletal stiffness and deep vein thrombosis by promoting venous return. While important for overall recovery, they do not directly expand lung tissue or prevent pulmonary secretions from accumulating in the bronchioles.

Choice C rationale

Expectorants assist in thinning mucus but do not address the primary postoperative risk of hypoventilation or lung collapse. Preventive care prioritizes mechanical expansion of the lungs over pharmacological management of secretions unless a cough is present.

Choice D rationale

Suction equipment is a reactive measure used when secretions already obstruct the airway. Preventive care focuses on proactive lung expansion techniques rather than the equipment needed for emergency or symptomatic management of existing pulmonary distress.

The scenario requires evaluating surgical and medical history to identify specific factors that increase the probability of clot formation. Knowledge of Virchow's triad, involving venous stasis, endothelial injury, and hypercoagulability, is applied to differentiate between general health issues and specific VTE risks.

Choice A rationale

A history of previous deep vein thrombosis is one of the strongest predictors for future occurrences. Past events indicate a predisposition to hypercoagulability or existing vascular damage, which significantly increases the risk during periods of surgical immobilization.

Choice B rationale

While hypertension is a significant cardiovascular risk factor for stroke or myocardial infarction, it is not traditionally categorized as a direct independent trigger for venous thromboembolism. It affects the high-pressure arterial system rather than the venous system.

Choice C rationale

Remote surgical history like a cholecystectomy does not present an active risk for a current procedure. Only the immediate perioperative period of the current surgery or a very recent surgery within thirty days contributes to VTE risk.

Choice D rationale

Major orthopedic surgeries, specifically total hip arthroplasties, carry an extremely high risk for VTE due to extensive local tissue trauma and prolonged venous stasis. These procedures require aggressive prophylaxis because they often cause direct venous endothelial injury.

Choice E rationale

A Body Mass Index of 30.1 indicates obesity, which increases intra-abdominal pressure and slows venous return from the lower extremities. This venous stasis, combined with chronic systemic inflammation associated with adipose tissue, raises the risk of clot formation.

Choice F rationale

High cholesterol, or hyperlipidemia, is a primary driver for atherosclerosis within the arterial system. While it impacts overall vascular health, it is not a primary or direct risk factor for developing venous thromboembolism in the perioperative setting.

Choice G rationale

Smoking causes significant endothelial dysfunction and increases blood viscosity, even if the client quit two years ago. The long-term damage to the vascular lining and chronic changes in coagulation factors contribute to an elevated risk profile.