A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol.
Which intervention is most important for the nurse to include in this client’s plan of care?

Observe for bleeding side effects related to heparin therapy.

Encourage mobilization to prevent pulmonary embolism.

Assess blood pressure and heart rate at least every 4 hours.

Measure each calf’s girth to evaluate edema in the affected leg.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Heparin is an anticoagulant medication that prevents the formation of blood clots. One of the most common and serious side effects of heparin therapy is bleeding. Therefore, it is crucial for the nurse to observe for signs of bleeding, such as bruising, petechiae, hematomas, black tarry stools, hematuria, and changes in mental status. Regular laboratory monitoring of the client’s coagulation status, specifically the activated partial thromboplastin time (aPTT), is also necessary to ensure therapeutic levels of heparin without causing excessive bleeding.

Choice B rationale

While mobilization can help prevent the formation of new clots, it is not the most important intervention for a client who is already on a heparin protocol for DVT. Mobilization can potentially dislodge the existing clot, leading to a life-threatening pulmonary embolism.

Choice C rationale

Although it is important to monitor vital signs in all clients, assessing blood pressure and heart rate every 4 hours is not the most important intervention for a client on a heparin protocol.

Changes in blood pressure and heart rate are not specific to heparin therapy and do not provide direct information about the effectiveness or side effects of the medication.

Choice D rationale

Measuring each calf’s girth can help evaluate the progression of edema in the affected leg, but it is not the most important intervention for a client on a heparin protocol. While it can provide information about the local effects of the DVT, it does not address the systemic anticoagulation effects of heparin therapy.

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Correct Answer is ["A","D","E"]

Explanation

Choice A rationale
Teaching the client how to use guided imagery can be a helpful intervention for coping with feelings related to death and dying. Guided imagery can help the client to relax, reduce stress and anxiety, and find comfort.

Choice B rationale
Instructing the client and family to reconsider end of life choices is not typically an appropriate intervention. The nurse should respect the client’s end of life choices and provide support, rather than suggesting they reconsider.
Choice C rationale
Recording the client’s desire to live is not typically an intervention used in hospice care. The focus in hospice care is on providing comfort and quality of life, rather than on prolonging life.
Choice D rationale
Encouraging the family to bring the client old photographs can be a helpful intervention. Looking at old photographs can stimulate memories and conversations, providing comfort and connection.
Choice E rationale
Encouraging the family to visit frequently can be a beneficial intervention. Frequent visits can provide the client with emotional support and companionship, which can be comforting when coping with feelings related to death and dying.

A. It reduces the amount of HCl secreted by the parietal cells in the stomach. B. It destroys the microorganisms causing inflammation in the stomach. C. It neutralizes hydrochloric acid (HCl) in the stomach. D. It inhibits the action of acetylcholine by blocking parasympathetic nerve endings.

Correct Answer is A

Explanation

Choice A rationale
Histamine H2-receptor antagonists, also known as H2 blockers, are medications that help reduce the production of gastric acid. They achieve this by blocking H2 receptors in the parietal cells of the stomach, which are responsible for secreting hydrochloric acid (HCl)12. This reduction in acid secretion can help treat conditions such as peptic ulcers, gastroesophageal reflux disease (GERD), and Zollinger-Ellison syndrome, which are all conditions that can be exacerbated by excessive stomach acid.
Choice B rationale
While H2 blockers do help manage the symptoms of peptic ulcer disease, they do not directly destroy the microorganisms causing inflammation in the stomach. The primary cause of peptic ulcers is a bacterium called Helicobacter pylori, and the treatment for an H. pylori infection typically involves a combination of antibiotics and proton pump inhibitors, not H2 blockers.
Choice C rationale
H2 blockers do not neutralize hydrochloric acid (HCl) in the stomach. Instead, they work by reducing the amount of acid produced by the stomach. Antacids, not H2 blockers, are the class of drugs that work by neutralizing stomach acid.
Choice D rationale
H2 blockers do not inhibit the action of acetylcholine by blocking parasympathetic nerve endings. Anticholinergic medications are the ones that work by blocking the action of acetylcholine, a neurotransmitter that transmits signals in the nervous system.

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A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

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Explanation

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A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol.
Which intervention is most important for the nurse to include in this client’s plan of care?