- A 72-year-old client is postoperative day 1 after open right hemicolectomy for colon cancer. History includes obesity and hypertension. Assessment: temperature 37.0°C (98.6°F), heart rate 96/min, blood pressure 138/78 mm Hg, respiratory rate 18/min, oxygen saturation 96% on room air; client reports incisional pain 7/10 and has remained in bed except to use the bedside commode; sequential compression devices (SCDs) are at the bedside but not on the legs. Which intervention should the nurse implement to prevent DVT in this client?
Answer: Apply the sequential compression devices and ensure they remain on while the client is in bed
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of risk reduction through mechanical prophylaxis and early mobility. Applying sequential compression devices (SCDs) and ensuring they remain on while the client is in bed is the best choice because it promotes venous return and prevents stasis in a high-risk client who has been immobile. Requesting a venous ultrasound (A) is not indicated without symptoms of DVT, delegating ambulation (C) is premature given the client's pain and limited mobility, and reassessing pulses and circumference (D) is monitoring rather than preventive action. The decision-making principle is to prioritize non-pharmacological interventions like SCDs in immobile postoperative clients to reduce Virchow's triad factors. Additionally, combining SCDs with gradual ambulation addresses stasis effectively. A transferable prevention strategy is to routinely apply and monitor SCDs in all bedbound postoperative clients unless contraindicated.
- A 58-year-old client is postoperative day 1 after abdominal hysterectomy and is receiving enoxaparin for DVT prophylaxis. History includes peptic ulcer disease. Assessment: heart rate 88/min, blood pressure 118/70 mm Hg, respiratory rate 16/min, oxygen saturation 98% on room air; client reports new black, tarry stools and dizziness when standing. The nurse should QUESTION which order related to DVT prophylaxis?
Answer: Administer the next scheduled enoxaparin dose now
This question tests the nurse's knowledge of preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) in postoperative clients, specifically identifying when to question pharmacological prophylaxis due to potential complications. The priority framework here is patient safety protocols, balancing thrombosis risk reduction with the prevention of hemorrhage. Administering the next scheduled enoxaparin dose now is the order that should be questioned, as it poses the highest risk due to the client's signs of gastrointestinal bleeding (black, tarry stools) and orthostatic hypotension (dizziness when standing), exacerbated by a history of peptic ulcer disease, making anticoagulant continuation unsafe. The distractors are incorrect to question because (A) early ambulation promotes venous return without bleeding risk, (B) sequential compression devices (SCDs) offer safe mechanical prophylaxis, and (D) ankle pumps and leg exercises encourage circulation non-invasively, all supporting DVT prevention appropriately. The decision-making principle in DVT/PE prevention requires ongoing assessment for anticoagulant contraindications like active bleeding. When such risks are present, nurses should withhold the medication and notify the provider immediately to adjust the plan. A transferable prevention strategy for postoperative care is to use a multimodal approach, integrating mechanical methods and mobility alongside tailored pharmacological options based on individual bleeding risks.
- A 58-year-old client is postoperative day 1 after bariatric surgery. History includes obesity, type 2 diabetes, and obstructive sleep apnea. Assessment: heart rate 108/min, blood pressure 136/84 mm Hg, respiratory rate 20/min, oxygen saturation 93% on room air; client reports new unilateral left calf pain and tightness; left calf is warm compared with the right. What is the PRIORITY nursing action to prevent PE?
Answer: Keep the client on bed rest, elevate the affected leg, and notify the provider of suspected DVT
Suspect a DVT: after bariatric surgery, obesity, diabetes, and sleep apnea already raise thrombotic risk, and the unilateral calf pain, warmth, and tachycardia with mild hypoxemia suggest a clot has formed. The priority is to keep the client on bed rest, elevate the affected leg, and notify the provider; immobilization keeps the thrombus in place, and prompt notification leads to diagnostic testing and treatment that prevent embolization to the lungs. Ambulating the client immediately, even with assistance, can dislodge the clot and is dangerous. Applying or increasing SCD compression over a suspected DVT is also contraindicated because it can fragment the thrombus. Measuring the calf circumference and comparing it with the right leg are reasonable assessments, but reassessing in one hour without notifying the provider is a delay, not a priority action. The correct nursing action combines bed rest, elevation, and early provider notification.
- A 59-year-old client is 8 hours postoperative after total abdominal hysterectomy. History includes prior deep vein thrombosis (DVT) 6 years ago and current smoker. Assessment: heart rate 104/min, blood pressure 126/74 mm Hg, respiratory rate 20/min, oxygen saturation 94% on room air; client is drowsy from opioids and reluctant to move; SCDs are in place, and enoxaparin prophylaxis is ordered to start tonight. What is the PRIORITY nursing action to prevent pulmonary embolism (PE)?
Answer: Maintain SCD use and assist the client to perform ankle pumps and leg exercises every hour while awake
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of safety protocols including mechanical and pharmacological prophylaxis. Maintaining SCD use and assisting with ankle pumps and leg exercises every hour while awake is the best choice as it directly combats venous stasis in a drowsy, high-risk client with prior DVT history. Encouraging incentive spirometry (A) focuses on respiratory rather than venous issues, obtaining a D-dimer (C) is unnecessary before enoxaparin unless bleeding risk is suspected, and prescribing bed rest (D) increases stasis and DVT risk. The decision-making principle is to integrate mechanical prophylaxis with active exercises to enhance circulation. This approach is crucial for clients with multiple risk factors like smoking and immobility. A transferable prevention strategy is to promote hourly leg exercises in all postoperative clients on prophylaxis to minimize clot formation.
- A 70-year-old client is postoperative day 1 after a left total knee arthroplasty; history includes prior deep vein thrombosis 5 years ago and obesity. Assessment: heart rate 90/min, blood pressure 140/82 mm Hg, respiratory rate 18/min, oxygen saturation 96% on room air; the client can stand with a walker but prefers to stay in bed; prescribed prophylaxis includes intermittent pneumatic compression and early ambulation. Which intervention should the nurse implement to prevent DVT in this client?
Answer: Initiate intermittent pneumatic compression while in bed and assist with early ambulation
This question tests prevention of DVT/PE in postoperative clients. The priority framework is implementing prescribed mechanical and activity-based prophylaxis for high-risk patients. Initiating intermittent pneumatic compression and assisting with early ambulation (B) is the best choice because this client has a history of DVT and multiple risk factors, making both interventions essential. Elevating legs under the knee (A) can impede venous return, assessing pulses and delaying activity (C) contradicts early mobilization principles, and delegating ambulation only to PT (D) reduces mobilization opportunities. The decision-making principle is that patients with prior DVT require aggressive mechanical prophylaxis combined with early mobilization. The transferable strategy is to implement all prescribed prophylactic measures consistently, especially for patients with DVT history.
- A 56-year-old client is postoperative day 2 after right total knee arthroplasty. History includes osteoarthritis and obesity. Assessment: temperature 37.1°C (98.8°F), heart rate 92/min, blood pressure 134/80 mm Hg, respiratory rate 18/min, oxygen saturation 97% on room air; client is using a continuous passive motion device and ambulates short distances with physical therapy. Which intervention should the nurse implement to prevent DVT in this client?
Answer: Encourage adequate hydration, apply prescribed compression devices, and reinforce participation in early ambulation
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of safety protocols combining multiple strategies. Encouraging adequate hydration, applying prescribed compression devices, and reinforcing participation in early ambulation is best to address stasis and hypercoagulability. Avoiding movement of the operative leg (B) increases risk, massaging the calf (C) risks embolization, and placing a pillow under the knee (D) promotes stasis. The decision-making principle is to integrate hydration, mechanical, and mobility interventions for comprehensive prevention. This is essential post-orthopedic surgery. A transferable prevention strategy is to ensure multimodal prophylaxis in all joint replacement clients.
- A 62-year-old client is postoperative day 1 after bariatric surgery; history includes obstructive sleep apnea and limited mobility. Medications include unfractionated heparin 5,000 units subcutaneously every 8 hours for DVT prophylaxis. Assessment: heart rate 86/min, blood pressure 124/76 mm Hg, respiratory rate 16/min, oxygen saturation 95% on room air; the nurse notes new oozing at the incision and bleeding from the gums when the client brushes teeth. The nurse should take which action FIRST?
Answer: Hold the next heparin dose and notify the provider of signs of bleeding
This question tests prevention of DVT/PE in postoperative clients. The priority framework is recognizing and responding to anticoagulation complications while maintaining DVT prevention. Holding the heparin dose and notifying the provider (A) is the priority because oozing at the incision and gum bleeding indicate potential over-anticoagulation requiring immediate intervention. Applying SCDs (B) is appropriate but doesn't address the bleeding, rechecking BP (C) is not indicated as vitals are stable, and delegating dressing checks (D) delays necessary nursing assessment. The decision-making principle is that signs of bleeding in patients on anticoagulation require immediate dose adjustment to prevent hemorrhage while maintaining DVT protection. The transferable strategy is to monitor for bleeding complications in anticoagulated postoperative patients and act promptly to prevent hemorrhage.
- A 65-year-old client is postoperative day 1 after gastric surgery and has a new order for intermittent pneumatic compression (IPC) devices. History includes obesity and prior stroke with residual weakness. Assessment: heart rate 92/min, blood pressure 128/70 mm Hg, respiratory rate 16/min, oxygen saturation 97% on room air; the client is weak and needs assistance to reposition. Which intervention should the nurse implement to prevent DVT in this client?
Answer: Apply IPC devices and assess skin and device function routinely while encouraging mobility as tolerated
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of risk reduction using mechanical devices. Applying IPC devices and assessing skin and device function routinely while encouraging mobility as tolerated is best to promote venous return in a weak client. Applying only during ambulation (B) misses rest periods, keeping legs dependent (C) promotes stasis, and delaying application (D) forgoes prevention. The decision-making principle is to monitor and maintain device integrity for effective prophylaxis. This is crucial with mobility limitations. A transferable prevention strategy is to routinely inspect compression devices in stroke history postoperative care.
- A 72-year-old client is postoperative day 1 after a right total hip arthroplasty and is on bed rest except to chair; medical history includes obesity and hypertension. Current assessment: temperature 37.1°C (98.8°F), heart rate 92/min, blood pressure 138/78 mm Hg, respiratory rate 18/min, oxygen saturation 96% on room air; the client reports pain 7/10 and has been reluctant to ambulate; sequential compression devices (SCDs) are at the bedside but not on the legs. Which intervention should the nurse implement to prevent DVT in this client?
Answer: Apply the sequential compression devices and verify they are functioning while the client is in bed
This question tests prevention of DVT/PE in postoperative clients. The priority framework is implementing mechanical prophylaxis for high-risk patients on bed rest. Applying sequential compression devices (SCDs) and verifying their function (A) is the best choice because this client has multiple risk factors (age, obesity, hip surgery, immobility) and the SCDs are available but not being used. Aspirin therapy (B) is not primary DVT prophylaxis and requires a prescription, ambulating now (C) is inappropriate as the client is on bed rest orders except to chair, and measuring calf circumferences (D) is assessment rather than prevention. The decision-making principle is that mechanical prophylaxis should be initiated immediately for immobile postoperative patients with risk factors. The transferable strategy is to ensure prescribed mechanical devices are actually applied and functioning, not just available at the bedside.
- A 71-year-old client is postoperative day 1 after right lobectomy. History includes chronic obstructive pulmonary disease and prior DVT. Assessment: heart rate 98/min, blood pressure 126/72 mm Hg, respiratory rate 20/min, oxygen saturation 94% on 2 L nasal cannula; client is hesitant to move due to chest tube discomfort and has not ambulated. What is the PRIORITY nursing action to prevent PE?
Answer: Administer analgesia as prescribed and assist with early mobilization and frequent leg exercises while maintaining mechanical prophylaxis
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of risk reduction through pain management and mobility. Administering analgesia as prescribed and assisting with early mobilization and frequent leg exercises while maintaining mechanical prophylaxis is the priority to prevent stasis despite discomfort. Increasing oxygen (B) addresses hypoxemia but not DVT, obtaining ABG (C) is diagnostic, and delegating ambulation (D) delays action. The decision-making principle is to alleviate pain to facilitate movement, reducing PE risk. This is vital in respiratory-compromised clients. A transferable prevention strategy is to prioritize pain control for mobility in thoracic surgery postoperative care.
- A 48-year-old client is postoperative day 3 after laparoscopic cholecystectomy and has been mostly bedridden due to nausea. History includes oral contraceptive use and obesity. Assessment: temperature 37.2°C (99.0°F), heart rate 110/min, blood pressure 118/70 mm Hg, respiratory rate 22/min, oxygen saturation 92% on room air; the client reports sudden shortness of breath and pleuritic chest pain. Which assessment finding requires IMMEDIATE intervention to prevent PE?
Answer: New onset oxygen saturation 92% on room air with sudden dyspnea
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of safety protocols for recognizing and responding to PE symptoms. New onset oxygen saturation 92% on room air with sudden dyspnea requires immediate intervention as it suggests possible PE in a bedridden client with risk factors. Nausea with decreased intake (B), incisional discomfort (C), and no bowel movement (D) are common postoperative issues but not indicative of acute PE. The decision-making principle is to prioritize rapid assessment and intervention for respiratory distress to prevent PE progression. Early recognition of hypoxia and dyspnea guides escalation of care. A transferable prevention strategy is to monitor oxygen saturation closely in immobile postoperative clients and intervene promptly for desaturation.
- A 66-year-old client is postoperative day 2 after left total hip arthroplasty. History includes type 2 diabetes and chronic kidney disease stage 3. Current orders include early ambulation, SCDs, and enoxaparin 40 mg subcutaneous daily for DVT prophylaxis. Assessment: incision clean/dry, pain controlled, ambulating with a walker twice daily. The nurse should QUESTION which order related to DVT prophylaxis?
Answer: Massage the calves for 5 minutes each shift to improve venous return
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of risk reduction by questioning unsafe orders. Massaging the calves for 5 minutes each shift should be questioned because it can dislodge potential clots, increasing PE risk, especially in a postoperative client. Applying SCDs (A) is appropriate mechanical prophylaxis, encouraging fluids and ambulation (B) promotes circulation safely, and administering enoxaparin (D) is standard pharmacological prophylaxis despite CKD, though dose adjustment may be needed. The decision-making principle is to avoid interventions that could embolize clots, such as massage, in at-risk clients. Prioritizing safe mobility over manual manipulation prevents complications. A transferable prevention strategy is to educate staff on contraindications like calf massage in all postoperative DVT prophylaxis protocols.
- A 69-year-old client is postoperative day 1 after open abdominal aortic aneurysm repair. History includes chronic kidney disease and hypertension. Orders include SCDs and low-dose unfractionated heparin prophylaxis. Assessment: heart rate 88/min, blood pressure 110/64 mm Hg, respiratory rate 16/min; the client has active bleeding at the surgical drain site with increasing drainage and new ecchymosis. The nurse should QUESTION which order related to DVT prophylaxis?
Answer: Administer scheduled unfractionated heparin prophylaxis dose now
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of risk reduction by questioning orders amid complications. Administering scheduled unfractionated heparin should be questioned due to active bleeding, which increases hemorrhage risk. Continuing SCDs (A) is safe mechanical prophylaxis, encouraging exercises (C) promotes circulation without bleeding risk, and assisting with dangling (D) supports mobility safely. The decision-making principle is to withhold anticoagulants when bleeding is present to avoid complications. Mechanical methods remain appropriate alternatives. A transferable prevention strategy is to prioritize non-pharmacological prophylaxis in postoperative clients with bleeding risks.
- A 55-year-old client is postoperative day 2 after spinal fusion; history includes obesity and varicose veins. Assessment: heart rate 94/min, blood pressure 130/80 mm Hg, respiratory rate 18/min, oxygen saturation 96% on room air; the client ambulates only to the bathroom with assistance and spends most of the day in bed. Which intervention should the nurse implement to prevent DVT in this client?
Answer: Maintain sequential compression devices while in bed and encourage frequent ambulation as tolerated
This question tests prevention of DVT/PE in postoperative clients. The priority framework is combining mechanical prophylaxis with mobility interventions for high-risk patients. Maintaining SCDs while in bed and encouraging frequent ambulation (B) is the best choice because this client has multiple risk factors (obesity, varicose veins, limited mobility) requiring both interventions. Encouraging fluids (A) addresses hydration but not venous stasis, assessing calves once per shift (C) is insufficient monitoring, and placing pillows under knees (D) can impede venous return. The decision-making principle is that high-risk patients need continuous mechanical prophylaxis when immobile plus frequent mobilization attempts. The transferable strategy is to ensure mechanical devices are used consistently during bed rest while maximizing ambulation opportunities for postoperative patients.
- A 73-year-old client is postoperative day 3 after left hip fracture repair. History includes dementia and prior DVT. Assessment: heart rate 96/min, blood pressure 142/80 mm Hg, respiratory rate 18/min, oxygen saturation 95% on room air; the client repeatedly removes SCDs and refuses to ambulate; enoxaparin prophylaxis is scheduled. Which intervention should the nurse implement to prevent DVT in this client?
Answer: Apply SCDs, use frequent reorientation and supervision, and coordinate with the team for safe, assisted mobilization
Prevention must be safe and individualized to the client's cognitive status. The best choice applies the SCDs and, because the client repeatedly removes them, pairs that with frequent reorientation, supervision, and coordinated safe, assisted mobilization. This preserves both mechanical and early-mobility prevention. The client is at high risk from recent surgery, prior DVT, and reduced mobility, so stopping or postponing prevention is unsafe. Restraints do not address why the client removes the SCDs and add physical and emotional risks; they are not an acceptable prevention strategy. Stopping enoxaparin because of fall risk misapplies risk-benefit judgment: dementia-related fall risk is not a contraindication, and omitting an ordered anticoagulant removes DVT protection. Assessing the calves for redness, warmth, and swelling is surveillance, not prevention, and delaying mobility until tomorrow increases venous stasis and clot risk. The correct nursing response is to adapt the prevention plan through reorientation, supervision, and safe assistance with mobilization despite the client's noncompliance.
- A 54-year-old client is postoperative day 2 after colorectal surgery. History includes cancer and dehydration on admission. Assessment: heart rate 106/min, blood pressure 112/68 mm Hg, respiratory rate 18/min, oxygen saturation 96% on room air; urine output is low and mucous membranes are dry; client has been reluctant to walk. Which intervention should the nurse implement to prevent DVT in this client?
Answer: Encourage oral fluids as allowed, administer intravenous fluids as prescribed, and promote early ambulation and leg exercises
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of safety protocols addressing dehydration. Encouraging oral fluids as allowed, administering intravenous fluids as prescribed, and promoting early ambulation and leg exercises is best to reduce hypercoagulability and stasis. Restricting fluids (B) worsens dehydration, applying warm compresses (C) is not preventive, and collecting urine (D) is unrelated. The decision-making principle is to correct fluid deficits to prevent clot formation. Mobility complements hydration efforts. A transferable prevention strategy is to monitor and optimize hydration status in all dehydrated postoperative clients.
- A 63-year-old client is postoperative day 0 after radical prostatectomy. History includes hyperlipidemia and obstructive sleep apnea. Assessment: heart rate 92/min, blood pressure 132/76 mm Hg, respiratory rate 14/min, oxygen saturation 95% on 2 L nasal cannula; client is sleepy and has not ambulated yet; SCDs are in place. Which intervention should the nurse implement to prevent DVT in this client?
Answer: Administer prescribed analgesics and assist the client to sit at the edge of the bed and ambulate as tolerated
Early postoperative mobility is the priority for DVT prevention. This client is sleepy but stable, with no bleeding concerns, so the best action is to give prescribed analgesics first and then assist the client to sit at the edge of the bed and ambulate as tolerated. Pain control makes mobility possible, and walking engages the calf muscle pump to improve venous return. Encouraging the client to cross the legs at the ankles does not prevent DVT and actually promotes venous stasis by compressing vessels. Removing the SCDs during sleep interrupts the compression prophylaxis that is meant to run continuously. Obtaining a coagulation panel before mobility is unnecessary because the assessment shows no bleeding risk, and the delay in mobilizing would increase thrombus risk. The key is pairing analgesia with early ambulation — treat the pain, then get the client moving.
- A 67-year-old client is postoperative day 4 after abdominal surgery and has been refusing SCDs because they are "too tight." History includes varicose veins and obesity. Assessment: heart rate 102/min, blood pressure 130/78 mm Hg, respiratory rate 18/min, oxygen saturation 95% on room air; client ambulates only once daily. Which intervention should the nurse implement to prevent DVT in this client?
Answer: Assess SCD fit and skin, educate on purpose, and reapply with correct sizing while promoting frequent ambulation
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of safety protocols addressing noncompliance. Assessing SCD fit and skin, educating on purpose, and reapplying with correct sizing while promoting frequent ambulation is best to ensure compliance and prevent stasis. Removing SCDs permanently (A) eliminates prophylaxis, encouraging bed rest (C) increases risk, and delegating teaching (D) is inappropriate for client education. The decision-making principle is to troubleshoot barriers to prophylaxis like discomfort. Education enhances adherence to preventive measures. A transferable prevention strategy is to regularly evaluate and adjust mechanical devices for comfort in all noncompliant postoperative clients.
- A 57-year-old client is postoperative day 2 after spinal fusion. History includes obesity and limited mobility. Assessment: heart rate 90/min, blood pressure 136/78 mm Hg, respiratory rate 16/min, oxygen saturation 97% on room air; client reports new unilateral calf swelling and pain; the calf is warm and tender. What is the PRIORITY nursing action to prevent PE?
Answer: Notify the provider and keep the client on bed rest with the affected leg elevated
Notify the provider and keep the client on bed rest with the affected leg elevated is the priority because this client shows classic signs of a deep vein thrombosis: new unilateral calf swelling, warmth, and tenderness after spinal fusion with obesity and limited mobility. If a clot is present, immobilization and prompt escalation are essential to prevent a pulmonary embolism. Encouraging the client to ambulate with assistance is unsafe once DVT is suspected because movement can dislodge the clot. Applying a heating pad is a comfort measure that does not reduce embolic risk and may worsen inflammation. Reassessing vital signs in thirty minutes, even if the provider is notified afterward, delays diagnosis and treatment; vital signs can remain normal until a PE occurs. The immediate priority is to stabilize the clot and get the provider involved.
- A 70-year-old client is postoperative day 2 after partial colectomy. History includes atrial fibrillation (not anticoagulated pre-op) and chronic anemia. Current medications include unfractionated heparin 5,000 units subcutaneous every 8 hours for prophylaxis. Assessment: heart rate 90/min, blood pressure 128/72 mm Hg, respiratory rate 16/min; new oozing noted from the abdominal incision and gums bleed with oral care. Client is still mostly in bed. Which nursing action best addresses DVT/PE prevention while monitoring for anticoagulant complications?
Answer: Hold the next heparin dose and notify the provider of bleeding findings
This question tests prevention of DVT/PE in postoperative clients. It emphasizes the priority framework of safety protocols balancing prophylaxis and bleeding risk. Holding the next heparin dose and notifying the provider of bleeding findings is best to prevent complications while addressing DVT risk in an immobile client. Increasing heparin (B) worsens bleeding, massaging calves (C) risks embolization, and discontinuing SCDs (D) removes mechanical prophylaxis. The decision-making principle is to monitor for anticoagulant side effects and adjust therapy promptly. This prevents hemorrhage without neglecting DVT prevention. A transferable prevention strategy is to routinely assess for bleeding in postoperative clients on prophylaxis and escalate concerns immediately.
