A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)?

Ambulate the client.

Apply a warm moist pack.

Massage the client's leg.

Provide an ice pack.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Ambulation is contraindicated for a client with a confirmed deep vein thrombosis due to the significant risk of dislodging the thrombus. This could lead to a pulmonary embolism, a life-threatening complication. The nurse must ensure the client remains on bed rest to prevent this from occurring, thus this is not a delegated task for the AP.

Choice B rationale

Applying a warm moist pack is a safe and effective comfort measure for a client with a deep vein thrombosis. The warmth helps to promote vasodilation, which can reduce pain and inflammation associated with the DVT. This task is within the scope of practice for an assistive personnel to perform under the direct supervision of the nurse.

Choice C rationale

Massaging the leg of a client with a deep vein thrombosis is strictly contraindicated. This action can physically dislodge the thrombus from the vein wall, causing it to travel through the bloodstream. If the thrombus reaches the lungs, it becomes a pulmonary embolism, which is a medical emergency.

Choice D rationale

Applying an ice pack is not an appropriate comfort measure for a client with a deep vein thrombosis. Cold can cause vasoconstriction, which may worsen the pain and swelling associated with the DVT. It could also potentially increase the risk of thrombus formation by slowing blood flow.

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Correct Answer is C

Explanation

Choice A rationale

The 44-year-old client with pneumonia receiving intravenous antibiotics is at some risk due to potential immobility and fever, which can lead to diaphoresis and skin maceration. However, this client is likely mobile enough to shift positions independently or with minimal assistance, reducing the risk of sustained pressure. The client's age and general health status, aside from the acute infection, suggest good tissue perfusion and skin integrity.

Choice B rationale

A 26-year-old who is bedridden with a fractured leg is at significant risk due to immobility. The inability to shift weight and relieve pressure on bony prominences can lead to ischemia and tissue damage. However, younger individuals generally have better vascular supply, skin turgor, and faster cellular regeneration compared to older adults, which provides some protective physiological advantage against pressure injury development.

Choice C rationale

This 65-year-old client is at the greatest risk due to a combination of multiple risk factors. Hemiparesis leads to immobility and the inability to reposition, causing prolonged pressure on one side of the body. Incontinence exposes the skin to moisture and chemical irritants from urine and feces, leading to maceration and a breakdown of the skin's protective barrier, making it more susceptible to injury.

Choice D rationale

A 78-year-old requiring a walker for ambulation is at a lower risk for pressure injuries compared to a bedridden individual. Although advanced age and the need for assistive devices suggest some mobility limitations, the ability to ambulate, even with assistance, indicates the capacity to shift weight and relieve pressure on a regular basis. This regular movement promotes circulation and prevents prolonged periods of immobility.

Correct Answer is ["167"]

Explanation

Step 1 is to calculate the total infusion time in hours: 0700 - 1900 = 12 hours.

Step 2 is to calculate the infusion rate in mL/hour: 2000 mL ÷ 12 hours = 166.666. mL/hour.

Step 3 is to round the infusion rate to the nearest whole number as is common practice for IV pumps: 167 mL/hour. The final calculated infusion rate is 167 mL/hour.

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A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure injury development?

Correct Answer is C

Explanation

TPN 2,000 mL is ordered to infuse from 1900 to 0700. Using an IV controller, how many milliliters per hour should be infused?

Correct Answer is ["167"]

Explanation

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