A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?
Monitor for bleeding side effects related to heparin therapy.
Promote movement to prevent a pulmonary embolism.
Check blood pressure and heart rate at least every 4 hours.
Measure the circumference of each calf to assess for leg edema.
The Correct Answer is A
Choice A rationale
The most crucial intervention for a nurse to include in the care plan of a client with a deep vein thrombosis (DVT) in the left leg who is on a heparin protocol is to monitor for bleeding side effects related to heparin therapy. Heparin is an anticoagulant medication that prevents the formation of blood clots. While it is an effective treatment for DVT, it can also increase the risk of bleeding. Therefore, it is essential for the nurse to closely monitor the client for any signs of bleeding, such as unusual bruising, blood in urine or stool, or bleeding gums.
Choice B rationale
While promoting movement can help prevent a pulmonary embolism (a potential complication of DVT), it is not the most crucial intervention when a client is on a heparin protocol. Excessive movement can potentially dislodge the clot, leading to a pulmonary embolism. Therefore, while movement is important, it should be done under the guidance of a healthcare professional.
Choice C rationale
Checking blood pressure and heart rate at least every 4 hours is a standard nursing intervention for many clients, not just those with DVT. While it is important to monitor these vital signs, it is not the most crucial intervention for a client with DVT on a heparin protocol.
Choice D rationale
Measuring the circumference of each calf can help assess for leg edema, which can be a sign of DVT. However, this is not the most crucial intervention for a client on a heparin protocol. The priority is to monitor for bleeding side effects related to the heparin therapy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C,A,B,D
Explanation
Choice C rationale
The first step in managing a patient with abdominal pain and distention is to complete a focused assessment. This will help the nurse determine the severity of the patient’s condition and guide subsequent interventions.
Choice A rationale
Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has recently vomited. This is particularly important in this case as the patient’s vomit is dark brown, indicating possible upper gastrointestinal bleeding.
Choice B rationale
Sending the emesis sample to the lab is important for determining the cause of the patient’s symptoms. The lab can analyze the sample for the presence of blood or other abnormalities.
Choice D rationale
Offering PRN pain medication is important for patient comfort. However, it should be done after the assessment and initial interventions have been completed. The medication may mask symptoms that could provide important diagnostic information.
Correct Answer is D
Explanation
Choice A rationale
While it is essential to assess how the client copes with auditory hallucinations, asking this question alone does not provide specific information about the content of the hallucinations.
Choice B rationale
The timing of the voices can provide some insight into the triggers or patterns of the hallucinations, but it does not directly address the content or potential impact of the hallucinations on the client’s behavior or mental state.
Choice C rationale
While medication efficacy is an important aspect of managing schizophrenia, it does not directly address the current experience of the client’s hallucinations.
Choice D rationale
Understanding what the voices are saying to the client can provide critical information about potential risks, including self-harm or harm to others, and can guide the treatment plan. This is why it is the most important question for the nurse to include in the client’s assessment.
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