A nurse is caring for a client who has a deep vein thrombosis and a prescription for heparin. For which of the following findings should the nurse withhold the medication and notify the provider?

Choice A rationale:

The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.

Choice B rationale:

Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.

Choice C rationale:

Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.

Choice D rationale:

There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.

Choice A rationale:

Covering bedside water pitchers after being filled helps reduce the risk of contamination and infection by preventing the entry of airborne pathogens or debris.

Choice B rationale:

Allowing dressings that get wet in the shower to dry out is not an effective infection control strategy. Wet dressings can become a breeding ground for bacteria, and it is important to change wet dressings promptly to minimize the risk of infection.

Choice C rationale:

Used needles should be immediately disposed of in sharps containers, not placed at the nurses' station. Placing used needles in the sharps container promptly helps prevent accidental needlestick injuries and potential transmission of infections.

Choice D rationale:

Drainage bottles should be emptied regularly to prevent overfilling, but they should not be allowed to become full. Regular emptying ensures proper functioning and reduces the risk of spillage or contamination in the client care area.