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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Obtain a pair of slipper socks for the client. This is an appropriate action. Slipper socks can provide warmth and help improve circulation, promoting comfort.

B. Increase the client's oral fluid intake. While hydration is important for overall health, it will not directly address the cold feet caused by poor circulation in this scenario.

C. Place a moist heating pad under the client's feet. Heating pads, especially moist ones, can increase the risk of burns and should be avoided in clients with vascular occlusions, as they may have decreased sensation.

D. Rub the client's feet briskly for several minutes. Rubbing the feet briskly could cause skin breakdown and injury due to fragile skin and impaired circulation.

A. Limit movement of the lower extremities. B. Place sequential compression devices bilaterally. C. Massage lower extremities daily. D. Check for negative Homans' sign.

Correct Answer is B

Explanation

A. Limit movement of the lower extremities. Limiting movement increases the risk of venous stasis, which can lead to DVT. Regular movement and ambulation are encouraged to promote blood circulation.

B. Place sequential compression devices bilaterally. Sequential compression devices (SCDs) help promote venous return and prevent venous stasis, thereby reducing the risk of DVT.

C. Massage lower extremities daily. Massaging the legs is contraindicated in clients at risk for DVT because it can dislodge a clot and lead to pulmonary embolism.

D. Check for negative Homans' sign. The Homans' sign (pain in the calf on dorsiflexion of the foot) is not a reliable indicator of DVT and is no longer recommended as a standard assessment method.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?

Correct Answer is B

Explanation

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