The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the client's risk of this postoperative complication?
1. Administer an anticoagulant.
2. Assist the client to cough every 2 hours.
3. Monitor intake and output every 2 hours.
4. Provide for early ambulation.
Correct Answer: 4
Rationale 1: Anticoagulant therapy must be prescribed by a physician.
Rationale 2: Coughing every 2 hours will reduce the client's risk of developing pneumonia or atelectasis.
Rationale 3: Measuring intake and output every 2 hours assesses the client's renal function.
Rationale 4: Early ambulation, leg exercises, antiembolic stockings, SCDs, and adequate fluid intake are all interventions to reduce the risk for thrombophlebitis.
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