A client is immobile following surgery.

What should the nurse monitor for and what

interventions should be taken to prevent thrombus formation?
Suggested Fundamentals Learning Activity:  Mobility and Immobility

Assess for deep vein thrombosis by observing the calves for redness and palpating for warmth and
tenderness.
Measure the circumference of both calves and thighs and compare in size.
Instruct patients to avoid placing pillows under the knees or lower extremities, crossing the legs,
wearing tight clothes, sitting for long periods of time and massaging the legs.
Teach range of motion and anti-embolic exercises such as ankle pumps, foot circles, and knee
flexion.
Increase activity as soon as possible.
Use elastic stockings
Use SCD or IPC.
Increase fluid intake if there no restrictions.
Administer low dose heparin or enoxaparin prophylactically
Contact provider immediately if there is absence of a peripheral pulse in the lower extremities

A nurse is caring for a client who is receiving mechanical ventilation following a recent
surgery. The client has a previously placed nasogastric (NG) tube from another institution.
The provider's order directs to initiate enteral feedings via the NG tube. What data is
important to collect before initiating feedings?
Suggested Fundamentals Learning Activities:   Nasogastric Tube & Enteral Feeding

Before initiating feeding, review the prescription.

Assist the client to Fowler’s position or elevate bead of head to a minimum 30
Auscultate bowel sounds
Monitor tube placement: Check gastric contents for pH and aspirate for residual volume. Note
appearance and quantity of residual.
Flush the tubing with at least 30 mL tap water

Please list and discuss the indications and steps used during endotracheal suctioning.
 Suggested Fundamentals Learning Activity: Suctioning Techniques

Indications are when clients have early signs of hypoxemia (restlessness, confusion, tachypnea,
tachycardia, decreased Sp02 levels, adventitious breath sounds, audible or visible secretions,
cyanosis)

Use a suction catheter that does not exceed one half of the internal diameter of the endotracheal
tube to prevent hypoxia.
Hyperoxygenate the client using a bag-valve-mask or specialized ventilator function with an Fi)2
of 100%
Advance the catheter until resistance is met, then pull back 1cm.
Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15
seconds.
Use suction pressure no higher than 120 to 150 mm Hg.
Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger.
Limit each suction attempt to no longer than 10 to 15 seconds to avoid hypoxemia and the vagal
response.
Limit suctioning time to 5 minutes.

A nurse is reinforcing teaching with a client who has just been taught how to perform clean
intermittent self-catheterization for urinary retention. Describe the equipment the client will
need for this procedure.
Suggested Fundamental Learning Activity: Urinary Elimination
 
The client will need a straight catheter (8 to 10 Fr for children, 14 to 16 Fr for women and 16 to
18 Fr for men)
Soap and water
Water soluble lubricant
Collection container