The nurse is caring for a postoperative patient at risk for deep vein thrombosis. Which actions should the nurse recommend be included in the patient's plan of care? (Select all that apply.)

Question

a. Ambulate the patient tid.
b. Apply anti-embolic stockings.
c. Massage the patient's legs daily.
d. Place a pillow under the patient's knees.
e. Perform leg exercises 10 times hourly while awake.

Answer 1

ANS: A, B, E
For the patient at risk of developing deep vein thrombosis, it is important to encourage hourly leg exercises while awake, assist with early ambulation, apply knee- or thigh-length anti-embolic stockings, and give low molecular weight heparin if ordered. D. It is also important to avoid pressure under the knee from pillows to prevent clot formation. C. Legs should not be massaged, as a clot, if present, could be dislodged and become an embolus.