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.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale:

Use a peak flow meter to assess the respiratory status. Assessing the client's respiratory status using a peak flow meter is the most appropriate next action after administering albuterol, a bronchodilator. It helps determine the client's lung function and response to the medication. This information guides further interventions and treatment decisions.

Choice B rationale:

Administer a stat dose of corticosteroids. Administering corticosteroids may be indicated in some cases of respiratory distress or exacerbation of asthma. However, it should not be the immediate next step after albuterol administration. Assessing the client's response to albuterol through lung function testing (peak flow) is essential before deciding on additional medications.

Choice C rationale:

Document the normal finding in the client's health record. Documenting normal findings is important for maintaining accurate medical records, but in this case, it is premature. The nurse should first assess the client's response to albuterol and ensure that the respiratory status is indeed normal before documenting the findings.

Choice D rationale:

Repeat a dose of the client's rescue drug. Administering another dose of the rescue drug (albuterol) without assessing the client's response and lung function would not be the most appropriate action. It is essential to determine whether the initial dose was effective before considering additional doses or alternative treatments.

A. Serum sodium level. B. Hematocrit. C. Neutrophil count. D. Platelet count.

Correct Answer is C

Explanation

Choice A rationale:

Serum sodium level. Rationale: While electrolyte imbalances can be significant, in the context of purulent drainage at a postoperative site, monitoring serum sodium levels is not the top priority. Other laboratory values are more relevant in this situation.

Choice B rationale:

Hematocrit. Rationale: Hematocrit measures the proportion of red blood cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

Choice C rationale:

Neutrophil count. Rationale: Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.

Choice D rationale:

Platelet count. Rationale: Platelet count measures the number of blood clotting cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

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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 a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment?

Correct Answer is A

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is C

Explanation

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