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 B

Explanation

A. "Was your son born with this cardiac defect?" Rheumatic fever is an acquired condition, often following a streptococcal throat infection, not a congenital (born with) cardiac defect.

B. "Has your son had a sore throat recently?" Rheumatic fever commonly follows a streptococcal throat infection, so asking about a recent sore throat is relevant and important for diagnosis.

C. "Has your child had any injuries recently?" Recent injuries are unrelated to the development of rheumatic fever and are not a pertinent question.

D. "Are you aware that your son will have to be in isolation?" Isolation is not typically required for rheumatic fever, as it is not contagious in this stage.

A. Obtain a pair of slipper socks for the client. B. Increase the client's oral fluid intake. C. Place a moist heating pad under the client's feet. D. Rub the client's feet briskly for several minutes.

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.

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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

A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?

Correct Answer is B

Explanation

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

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