NCLEX-PN

Category - Basic Care

A client has given birth through a cesarean section 24 hours ago. The least effective action of the nurse in preventing thrombus formation is which of the following?
  1. Application of elastic compression stockings, as ordered
  2. Assisting in lower leg exercises every 2 hours
  3. Early ambulation
  4. Limiting the client’s fluid intake to 1500 mL daily
Explanation
Answer: D - The nurse should reinforce a fluid intake of 2500 mL per day. Limiting the client’s fluid intake to 1500 mL per day can increase the viscosity of the blood, which can cause thrombus formation. The other options are correct.
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