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 B

Explanation

A. Sitting with their head in their hands and appearing to cry indicates emotional distress rather than aggression or potential violence.

B. Pacing is often a sign of agitation or anxiety and can be indicative of a potential escalation to violence, especially in individuals with a history of aggressive behavior.

C. While expressing discontent with staff may show frustration, it does not directly indicate imminent violence.

D. Taking numerous, deep breaths may suggest the client is attempting to calm themselves and is not a reliable indicator of potential aggression.

A. Attach the client's NG tube to low intermittent suction. B. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time. C. Instill chilled lavage solution into the client's NG tube. D. Use 0.9% sodium chloride for irrigation of the NG tube.

Correct Answer is D

Explanation

A. Attach the client's NG tube to low intermittent suction: Suction may be used after lavage for decompression, but during lavage, the focus is on instilling and withdrawing solution manually to clear the stomach of blood or contents.
B. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time: This volume is excessive and could increase the risk of aspiration or discomfort. Typically, 100–200 mL is used per instillation.
C. Instill chilled lavage solution into the client's NG tube: Chilled solutions are not recommended as they may induce hypothermia and have not been shown to effectively control bleeding. Room-temperature solution is preferred.
D. Use 0.9% sodium chloride for irrigation of the NG tube: Isotonic saline is the recommended solution for gastric lavage, as it helps prevent electrolyte imbalance and irritation.

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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?

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Naxlex Comprehensive Predictor Exams

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