Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

Leg exercises not performed because of placement of antiembolism hose.

Antiembolism stockings removed hourly during leg exercises.

Client demonstrates ability to move all extremities well.

Antiembolism stockings on, leg exercises performed hourly.

Answer and Explanation

The Correct Answer is D

Choice D rationale:

"Antiembolism stockings on, leg exercises performed hourly" indicates that activities to prevent postoperative venous stasis were performed correctly. This combination ensures both mechanical prophylaxis (antiembolism stockings) and physical activity (leg exercises) to prevent blood clots in postoperative patients.

Choice A rationale:

"Leg exercises not performed because of placement of antiembolism hose" is not the correct approach. Leg exercises should be encouraged even when antiembolism stockings are worn, as they have complementary benefits in preventing venous stasis.

Choice B rationale:

"Antiembolism stockings removed hourly during leg exercises" is not recommended. Antiembolism stockings should be worn continuously to be effective in preventing venous stasis.

Choice C rationale:

"Client demonstrates the ability to move all extremities well" is a good sign of the client's mobility but does not confirm that the specific activities to prevent postoperative venous stasis were performed correctly. The combination of stockings and leg exercises is more comprehensive.

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Correct Answer is B

Explanation

Choice A rationale:

Tenderness is not considered a normal finding during percussion of the abdomen. Tenderness suggests an underlying issue or inflammation in the abdominal area, which requires further evaluation and investigation.

Choice B rationale:

Musical and drumlike sounds are considered normal findings during percussion of the abdomen. These sounds indicate the presence of air-filled structures like the stomach or intestines. Normal abdominal percussion sounds are tympanic, and they are characterized by a hollow, drum-like quality when the abdomen is tapped lightly. This finding suggests that there are no significant abnormalities in the abdominal area.

Choice C rationale:

Absent sounds during abdominal percussion are not considered normal and may indicate a potential problem. Absent sounds could be due to factors such as bowel obstruction or severe constipation, which require further assessment and intervention.

Choice D rationale:

Pain during abdominal percussion is not considered a normal finding. It indicates discomfort or tenderness in the abdominal area, which requires further evaluation to determine the underlying cause.

A. Palpate for pedal edema. B. Assess blood pressure. C. Measure body temperature. D. Observe breathing patterns.

Correct Answer is B

Explanation

Choice A rationale:

Altered consciousness within the first 24 hours after injury is not indicative of a developing epidural hematoma. An epidural hematoma typically manifests as a lucid interval followed by a rapid deterioration in consciousness hours after the injury.

Choice B rationale:

Cushing reflex (increased blood pressure, bradycardia, and irregular respirations) and cerebral edema after 24 hours are characteristic signs of a developing epidural hematoma. This occurs due to the accumulation of blood between the dura mater and the skull, leading to increased intracranial pressure.

Choice C rationale:

Headache and pupillary changes 48 hours after head injury are not specific signs of an epidural hematoma. These symptoms may indicate various other neurological conditions or complications.

Choice D rationale:

Fever, nuchal rigidity, and opisthotonos within hours are suggestive of meningitis rather than an epidural hematoma. These symptoms are not typical of epidural hematomas, which primarily involve alterations in consciousness and increased intracranial pressure.

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Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

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