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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Sudden onset of confusion in an older adult could be a sign of a urinary tract infection (UTI). UTIs can cause delirium and behavioral changes in older adults. Therefore, asking if the client is experiencing any pain with urination could help identify a potential UTI.
Choice B rationale
While high protein foods are generally beneficial for health, there is no direct link between increased intake of high protein foods and sudden onset of confusion. Therefore, this option is not the most appropriate action in this situation.
Choice C rationale
Reviewing the client’s current food and medication allergies is always important in healthcare settings. However, it may not directly address the sudden onset of confusion unless the client has had a recent change in diet or medication that could have triggered an allergic reaction leading to confusion.
Choice D rationale
A recent fall could potentially cause a sudden change in mental status due to a head injury or other trauma. Therefore, determining if the client has recently experienced a fall is an appropriate action.
Choice E rationale
Fever can cause confusion, especially in older adults. Therefore, providing instruction on taking the client’s temperature can help the caregiver monitor for signs of infection that could be contributing to the client’s confusion.
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.
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