Examkin

Question

Difficulty: EasyReduction of Risk Potential

A nurse is caring for a client who is 12 hours postoperative following an open abdominal surgery. Which interventions should the nurse implement to reduce the client's risk of developing a venous thromboembolism (VTE)? Select all that apply.

  1. Apply sequential compression devices (SCDs) to the lower extremities.Answer
  2. Encourage the client to perform active ankle and foot exercises hourly while awake.Answer
  3. C
    Place a rolled pillow directly under the client's knees to relieve incisional tension.
  4. Assist the client with early ambulation as prescribed by the healthcare provider.Answer
  5. E
    Vigorously massage the client's calves if they report bilateral leg achiness.

Answer

The correct interventions are applying sequential compression devices, encouraging active leg exercises, and assisting with early ambulation.
Applying sequential compression devices, encouraging active leg exercises, and assisting with early ambulation are standard, evidence-based nursing interventions. These actions mechanically promote venous return, activate the calf muscle pump, and prevent blood stasis, thereby significantly reducing the risk of venous thromboembolism in immobile postoperative clients.

Step-by-Step Solution

1
Analyze the client's status and the clinical goal.
The client is postoperative and at risk for venous thromboembolism (VTE) due to immobility and surgical trauma. The goal is to identify actions that prevent blood stasis and promote venous return.
Understanding the physiological risks of the postoperative period guides appropriate prophylactic nursing care.
2
Evaluate each intervention for its effect on venous circulation.
SCDs, leg exercises, and ambulation all actively promote blood flow back to the heart. Pillows placed under the knees and leg massages are contraindicated.
Evidence-based practice dictates that nursing actions must support, not hinder, physiological processes.

Key Concept

Venous Thromboembolism (VTE) Prophylaxis
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic