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 D

Explanation

Choice A rationale:

Continue with the blood pressure assessment. Continuing with the blood pressure assessment without addressing the observed auscultatory gap could lead to an inaccurate reading. It's important to investigate and note the presence of an auscultatory gap before proceeding with the assessment.

Choice B rationale:

Reposition the stethoscope over the brachial artery. Repositioning the stethoscope may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.

Choice C rationale:

Reinflate the cuff to a higher number. Reinflating the cuff to a higher number without addressing the auscultatory gap can result in an inaccurate reading. The presence of an auscultatory gap should be noted and managed appropriately.

Choice D rationale:

Note the presence of an auscultatory gap. This is the correct choice. An auscultatory gap is a temporary disappearance of sounds during the blood pressure measurement, and it may indicate underlying cardiovascular issues. The nurse should note its presence, document it, and take appropriate action if necessary.

A. Assign the newly hired UAP to clients who require the least complex level of care. B. Ask the most experienced UAP on the team to partner with the newly hired UAP. C. Review the UAP's skills checklist and experience with the person who hired the UAP. D. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care.

Correct Answer is D

Explanation

Choice A rationale:

Assigning the newly hired unlicensed assistive personnel (UAP) to clients who require the least complex level of care is not the best approach to ensure adequate care for all clients. It may limit the UAP's opportunities for learning and growth and may not fully utilize their skills.

Choice B rationale:

Asking the most experienced UAP to partner with the newly hired UAP is a reasonable approach, but it may not provide a comprehensive solution. It can be beneficial for mentorship and guidance, but it may not address all the clients' needs efficiently.

Choice C rationale:

Reviewing the UAP's skills checklist and experience with the person who hired the UAP is an important step in assessing competency. However, it alone may not ensure adequate care for all clients. Competency assessment should be ongoing and include direct observation of care delivery.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is D

Explanation

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Correct Answer is D

Explanation

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