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 C
Explanation
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.
Correct Answer is D
Explanation
Choice A reason: A temperature of 37.3°C (99.1°F) is slightly elevated but not necessarily indicative of a bladder infection without other symptoms.
Choice B reason: A WBC count of 9,000/mm is within the normal range (4,500 to 11,000 WBC/mm) and does not specifically suggest a bladder infection.
Choice C reason: Diminished reflexes are not typically associated with bladder infections and may indicate neurological issues.
Choice D reason: In older adults, a change in mental status can be a sign of infection, including a bladder infection, especially when other typical symptoms may not be present.
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