A nurse is collecting data from a client who is postoperative and has a deep vein thrombosis of the right calf. Which of the following actions should the nurse take?
Apply cool compresses to the right calf.
Place the right leg in a dependent position.
Maintain the client on bed rest.
Decrease the client's fluid intake.
The Correct Answer is C
Choice A reason: Applying cool compresses may provide some relief but is not the primary action to be taken for DVT.
Choice B reason: Placing the leg in a dependent position can increase swelling and pain and is not recommended for DVT.
Choice C reason: Maintaining the client on bed rest is important to prevent the clot from dislodging and causing a pulmonary embolism.
Choice D reason: Decreasing fluid intake is not recommended as adequate hydration can help prevent further clot formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Cardiomegaly on a chest x-ray is a common finding in chronic heart failure and may not need immediate reporting unless there is a change in the client's condition.
Choice B reason: A urinary output of 1,000 mL in 12 hours is within normal limits.
Choice C reason: A potassium level of 4.5 mEq/L is within the normal range and not typically a concern.
Choice D reason: A PaCO2 of 55 mm Hg indicates respiratory acidosis and should be reported as it may signify worsening heart failure or respiratory distress.
Correct Answer is B
Explanation
Choice A reason: While pulling the fire alarm is important, the immediate priority is the safety of the client.
Choice B reason: The nurse's first action should be to remove the client from the room to ensure their safety from the potential fire.
Choice C reason: Closing the door may help contain smoke and fire, but it is not the first action to take before ensuring the client's safety.
Choice D reason: Obtaining a fire extinguisher is important after the client is safe and the alarm has been pulled to alert others.
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