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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
An elevated serum creatinine level can indicate kidney dysfunction or damage, which can be a possible adverse effect of amoxicillin-clavulanate. The kidneys are responsible for excreting the medication, and elevated creatinine levels suggest impaired renal function.
Choice B rationale:
An elevated serum alanine aminotransferase (ALT) level is indicative of liver dysfunction or damage. Amoxicillin-clavulanate can sometimes cause hepatotoxicity as a side effect, and elevated ALT levels may suggest this adverse effect.
Choice D rationale:
An elevated white blood cell count (leukocytosis) can be a possible adverse effect of amoxicillin-clavulanate, indicating an increase in the body's immune response. This could be due to an allergic reaction or other adverse reactions to the medication.
Choice C rationale:
An elevated serum potassium level is not typically associated with amoxicillin-clavulanate use. This finding is more likely related to other factors such as kidney dysfunction or certain medications like potassium-sparing diuretics.
Choice E rationale:
An elevated platelet count is not typically associated with amoxicillin-clavulanate use. This finding is more likely related to other factors, such as a bone marrow disorder or inflammation.
Correct Answer is C
Explanation
The correct answer is choice C: Increase rate of ventilation.
Choice A rationale:
Decreasing expiratory flow time would not directly address the elevated PaCO2 levels. This intervention is more related to managing expiratory phase issues rather than correcting respiratory acidosis.
Choice B rationale:
Decreasing expiratory pressure might help with certain ventilation issues, but it does not specifically target the elevated PaCO2 and resulting acidosis.
Choice C rationale:
Increasing the rate of ventilation helps to blow off more CO2, thereby reducing PaCO2 levels and correcting the respiratory acidosis indicated by the pH of 7.26 and PaCO2 of 68 mm Hg.
Choice D rationale:
Increasing the ventilator tidal volume could also help reduce PaCO2 by increasing the amount of air exchanged with each breath. However, increasing the rate of ventilation is generally a more immediate and effective intervention for acute respiratory acidosis.
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