A nurse is contributing to the care plan of a client who is postoperative and has an increased risk for deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan? (Select all that apply)
Assist with ordered exercise as needed
Encourage fluids
measure affected limb circumference
massage calves and thighs
Apply compression stockings
Correct Answer : A,B,C,E
A. Assist with ordered exercise as needed: Mobility and exercises such as ankle pumps help promote circulation and prevent venous stasis, reducing the risk of DVT.
B. Encourage fluids: Encouraging fluids helps prevent dehydration, which reduces blood viscosity and lowers the risk of clot formation.
C. Measure affected limb circumference: Measuring limb circumference is important for detecting early signs of DVT, such as swelling in the affected limb.
D. Massage calves and thighs: Massaging the legs is contraindicated in clients at risk for DVT as it can dislodge a clot, leading to a pulmonary embolism.
E. Apply compression stockings: Compression stockings promote venous return and reduce the risk of blood pooling in the lower extremities, thus preventing DVT.
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Related Questions
Correct Answer is D
Explanation
A. "Why have you changed your mind about the surgery?" Asking "why" may sound accusatory and could cause the client to feel defensive. It's more effective to use therapeutic communication techniques that encourage open expression of feelings.
B. "Your provider would not have scheduled the surgery unless you needed it."This response minimizes the client's concerns and implies that their feelings are not valid, which can hinder communication.
C. "I will call your doctor and have him discuss your surgery with you." While involving the provider is important, this response deflects the client's concerns without first addressing their feelings or providing support.
D. "Bypass surgery must be very frightening for you." This response uses a therapeutic communication technique by acknowledging the client’s emotions and opening the conversation for further exploration of their concerns.
Correct Answer is C
Explanation
A. Obtain platelet aggregation studies to confirm DVT. Platelet aggregation studies are not used to diagnose deep vein thrombosis (DVT). They are more relevant for evaluating platelet function and clotting disorders.
B. Schedule deep tissue massage with physical therapy. Deep tissue massage is contraindicated in clients suspected of having DVT, as it could dislodge the clot and cause a pulmonary embolism or other complications.
C. Arrange for a venous duplex ultrasound. A venous duplex ultrasound is the standard diagnostic test used to confirm DVT. It visualizes the veins and assesses blood flow, helping to detect the presence of a clot.
D. Monitor Homan's sign. Homan’s sign (pain in the calf with dorsiflexion of the foot) was once considered a diagnostic indicator of DVT, but it is no longer considered reliable due to its low sensitivity and specificity. Therefore, it is not routinely used for DVT diagnosis.
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