A postoperative client is at increased risk for venous thromboembolism. For each cue or action, select the best classification.
Matrix
Choose your responses, then check the answer.
Explanation
Postoperative VTE prevention is individualized to clotting and bleeding risk and may include prescribed pharmacologic prophylaxis, mechanical prophylaxis, and mobility. New unilateral swelling, warmth, or tenderness suggests possible DVT and requires prompt evaluation without massaging the limb. Sudden dyspnea, pleuritic chest pain, tachycardia, hypoxemia, syncope, or hypotension can indicate PE and requires emergency escalation.
Correct Answer Two rows are prevention, two suggest DVT evaluation, and two indicate possible PE requiring emergency action.
Why It Fits The cues progress from risk reduction to localized venous obstruction and then cardiopulmonary compromise.
Clinical Picture DVT can be subtle and PE can occur despite prophylaxis. The nurse does not delay escalation while trying to prove the diagnosis independently.
Memory Link Prevent in bed; evaluate one swollen leg; escalate sudden chest-breathing change.
NCLEX Rule Match the response to the highest current instability and avoid manipulating a limb with suspected DVT.
Why the Alternatives Fail Prophylaxis is not treatment for a new event. A leg-only cue does not by itself establish PE, while new hypoxemia or hypotension is more urgent than routine DVT workup.
Sources
1ASH VTE Prevention in Hospitalized Surgical Patients
2CDC: About Blood Clots
32026 NCLEX-RN Test Plan
The client is on postoperative day 2 after major abdominal surgery with limited mobility. Pharmacologic prophylaxis and sequential compression devices are prescribed. New leg or cardiopulmonary findings require the nurse to distinguish prevention from suspected DVT or PE.
Venous thromboembolism — The spectrum that includes deep vein thrombosis and pulmonary embolism.
Sequential compression device — A mechanical prophylaxis device that intermittently compresses the legs to support venous flow.