A client is at high risk for deep vein thrombosis (DVT) due to immobility. What should the nurse implement as a preventive measure for this client?
Encouraging active range of motion exercises.
Administering low-dose aspirin daily.
Applying a heating pad to the affected leg.
Providing a soft mattress for the client's bed.
The Correct Answer is A
A) This choice is correct. Encouraging active range of motion exercises helps prevent deep vein thrombosis (DVT) by promoting blood flow and reducing stasis in the veins. Moving the legs and ankles regularly helps prevent clot formation in immobilized clients.
B) This choice is incorrect because low-dose aspirin is not specifically indicated for preventing DVT. While aspirin may have some antiplatelet effects, it is not the primary preventive measure for DVT in high-risk clients.
C) This choice is incorrect because applying a heating pad to the affected leg is not a preventive measure for DVT. Heat application is not recommended for DVT prevention and could cause burns or injury.
D) This choice is incorrect because providing a soft mattress for the client's bed does not directly prevent DVT. The focus should be on encouraging movement and mobility to prevent DVT in clients at risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Measuring blood pressure is part of routine assessment and may help identify signs of bleeding. However, it does not directly address the most significant hematologic risk associated with enoxaparin therapy.
B. Assessing the client’s platelet count is essential prior to administration because low molecular weight heparins can cause thrombocytopenia, including heparin-induced thrombocytopenia. Reviewing platelet levels helps prevent serious complications such as bleeding or paradoxical clot formation.
C. Ensuring the presence of an indwelling urinary catheter is unrelated to the safe administration of enoxaparin and may actually increase infection risk. Catheter placement is not required for this medication.
D. Obtaining the client’s weight is important because dosing of enoxaparin is weight-based. However, screening for thrombocytopenia takes priority due to the potential for life-threatening complications.
Correct Answer is C
Explanation
A) This choice is incorrect because age and family history are non-modifiable risk factors for DVT. While they may increase the risk, they cannot be changed or controlled by the client.
B) This choice is incorrect because stopping prescribed anticoagulant medication is not recommended and may increase the risk of DVT. Anticoagulants are often prescribed to prevent or treat DVT and should not be discontinued without healthcare provider guidance.
C) This choice is correct. Smoking is a modifiable risk factor for DVT, and quitting smoking can reduce the risk of blood clot formation and other cardiovascular complications.
D) This choice is incorrect because while the client may have difficulty controlling a sedentary lifestyle, it is still considered a modifiable risk factor for DVT. Engaging in regular physical activity can help reduce the risk of blood clot formation.
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