A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take?

Apply a cold compress to the affected extremity.

Teach the client to massage the affected extremity.

Instruct the client to elevate the affected extremity when sitting.

Assess pulses proximal to the affected area.

Answer and Explanation

The Correct Answer is C

A. Applying a cold compress is not recommended for DVT; instead, heat may be more appropriate to alleviate discomfort and improve circulation.

B. Massaging the affected extremity is contraindicated as it can dislodge the clot and lead to complications such as pulmonary embolism.

C. Instructing the client to elevate the affected extremity helps reduce swelling and promote venous return, making it the best action.

D. Assessing pulses proximal to the affected area is important for monitoring circulation, but it is not the primary intervention for managing DVT.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Polyuria is not typically associated with immobility; instead, immobility can lead to urinary retention.

B. Contractures of the extremities occur due to prolonged immobility, leading to shortening of muscles and tendons.

C. Diarrhea is not a common complication of immobility; constipation is more frequently seen due to decreased mobility.

D. Crackles in the lungs can develop due to stasis of secretions and respiratory complications related to immobility.

E. Pressure ulcers develop from prolonged pressure on the skin due to immobility, especially over bony prominences.

A. Encourage friends and family to visit the child. B. Provide a low-protein diet for the child. C. Collect a daily urine specimen from the child to check for proteinuria. D. Withhold administering the varicella vaccine to the child.

Correct Answer is D

Explanation

A. Encouraging friends and family to visit the child is not appropriate due to the risk of infections, as the child has a severely compromised immune system.

B. A low-protein diet is not indicated; children with leukemia often require adequate nutrition to support their health.

C. Collecting a daily urine specimen for proteinuria is not specifically indicated for this condition; the focus should be on infection prevention.

D. Withholding the varicella vaccine is essential because live vaccines are contraindicated in immunocompromised patients due to the risk of severe infections.

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A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is D

Explanation

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