Answer to Question 1
ANS: B
Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of deep vein thrombosis. Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding. Pulmonary secretions that become thick and tenacious are difficult to remove and are a sign of inadequate hydration or developing pneumonia but not of bleeding. SCDs consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and are secured with Velcro. They decrease venous stasis by increasing venous return through the deep veins of the legs. They do not usually cause bleeding. Elastic stockings also aid in maintaining external pressure on the muscles of the lower extremities and in promoting venous return. They do not usually cause bleeding.
Answer to Question 2
ANS: B
The patient will walk 100 feet using a walker by the time of discharge is individualized, realistic, and measurable. Ambulating briskly on a treadmill is not realistic for this patient. The option that focuses on the nurse, not the patient, is not a measurable goal; this is an intervention. The patient will ambulate by the time of discharge is not measurable because it does not specify the distance. Even though we can see that the patient will ambulate, this does not quantify how far.
Documenting the health history is a crucial step in providing patient care
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