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
Explanation
Choice A rationale:
Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions.Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.
Choice B rationale:
Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.
Choice C rationale:
While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.
Choice D rationale:
Rapid intramuscular administration is incorrect for the same reasons as Choice B.Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.
Correct Answer is A
Explanation
- A terminally ill client is a client who has a progressive and incurable disease or condition that is expected to result in death within a short period of time, such as months or weeks. A terminally ill client may require palliative care, which is the care that focuses on relieving pain and suffering and improving the quality of life for the client and their family.
- An admission assessment is the process of collecting information about a client's health status, needs, preferences, and goals when they are admited to a health care facility, such as a hospital, nursing home, or hospice. An admission assessment helps to establish a baseline for the client's condition, plan and implement appropriate interventions, and evaluate the outcomes of care.
- A health care proxy is a legal document that allows a client to appoint another person, such as a family member or a friend, to make health care decisions for them if they become unable to do so themselves. A health care proxy may also include specific instructions or preferences about the type and extent of care that the client wishes to receive or refuse, such as life-sustaining treatments, resuscitation, or organ donation.
- Health care proxy documentation is an important information that the practical nurse (PN) should collect during the admission assessment of a terminally ill client to an acute care facility, as it reflects the client's autonomy, dignity, and wishes regarding their end-of-life care. It also helps to ensure that the client's healthcare decisions are respected and followed by the healthcare team and the facility.
- Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because the name of the funeral home to contact is not relevant or necessary for the admission assessment of a terminally ill client, as it does not affect their health status or care plan.
Option C is incorrect because the client's wishes regarding organ donation may be included in their health care proxy documentation, but they are not required or essential for the admission assessment of a terminally ill client.
Option D is incorrect because the contact information for the client's next of kin may be useful for communication and support purposes, but it is not as important as the health care proxy documentation for the admission assessment of a terminally ill client.
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