NCLEX Practice Test

A nurse is teaching an inservice regarding prevention of venous thromboembolism. Which nursing interventions should be included in the teaching? Select all that apply.

1. Administer scheduled anticoagulants

2. Apply sequential compression devices

3. Elevate the legs with pillows behind the knees

4. Have clients ambulate regularly as tolerated

5. Instruct clients to point and flex the feet in bed

The correct answer is: Administer scheduled anticoagulants

Administering scheduled anticoagulants is important in preventing venous thromboembolism because these medications help to prevent blood clots from forming. However, while elevating the legs with pillows behind the knees can improve circulation and minimize the risk of blood clots, it may not be enough to prevent venous thromboembolism on its own. Likewise, while applying sequential compression devices and instructing clients to point and flex their feet in bed may also improve circulation, these interventions are not recommended as standalone preventative measures. Additionally, although regular ambulation is important in promoting circulation and preventing venous thromboembolism, it may not be possible for all clients to ambulate regularly as tolerated. Therefore, while all of these interventions may contribute to the prevention of venous thromboembolism, administering scheduled anticoagulants is the most important and necessary intervention to include in the teaching.