A nurse is contributing to the plan of care for a client who is admitted with deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?
Apply ice to the extremity.
Administer vasodilating medications.
Restrict oral fluids.
Monitor platelet levels.
The Correct Answer is D
Choice A reason : Applying ice to the extremity is not a standard intervention for DVT. Ice is typically used to reduce inflammation and pain, but in the case of DVT, the priority is to prevent the clot from growing and embolizing. The use of warmth, not cold, may be recommended to help reduce discomfort and swelling.
Choice B reason : Administering vasodilating medications is not a typical intervention for DVT. Vasodilators are used to widen blood vessels and improve blood flow, but they do not address the risk of clot formation or embolization associated with DVT. The mainstay of medical treatment for DVT is anticoagulant therapy, which helps to prevent further clotting.
Choice C reason : Restricting oral fluids is not an intervention for DVT. Adequate hydration is important in the management of DVT as it can help to prevent blood from thickening and reduce the risk of further clot formation. There is no indication to restrict fluids unless there is another underlying condition that requires it.
Choice D reason : Monitoring platelet levels is an important intervention in the care of a client with DVT, especially if they are receiving anticoagulant therapy. Anticoagulants can affect platelet function and count, and monitoring is necessary to ensure safe levels and prevent complications such as bleeding or thrombocytopenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : Hepatomegaly, or the enlargement of the liver, is a common finding in right-sided heart failure. This condition occurs because the heart does not pump blood effectively, leading to congestion and increased pressure in the venous system, including the hepatic veins. As a result, the liver becomes engorged with blood, causing it to enlarge. The normal liver span in adults is about 10-12 cm in the midclavicular line, and any measurement above this can indicate hepatomegaly.
Choice B reason : Orthopnea, which is shortness of breath while lying flat, is more commonly associated with left-sided heart failure. In right-sided heart failure, symptoms are more related to systemic congestion, such as swelling in the legs and abdomen, rather than pulmonary symptoms like orthopnea.
Choice C reason : Dyspnea, or difficulty breathing, can be a symptom of both left and right-sided heart failure. However, in the context of right-sided heart failure, dyspnea is usually due to the accumulation of fluid in the abdominal cavity (ascites) and the increased pressure in the abdominal veins, which can compress the diaphragm and make breathing difficult.
Choice D reason : Frothy sputum is typically not a symptom of right-sided heart failure. It is more indicative of pulmonary edema, which is associated with left-sided heart failure. In right-sided heart failure, the primary issues are related to the systemic circulation and venous congestion.
Correct Answer is C
Explanation
Choice A reason : Advising a client with PVD not to go barefoot is correct. Going barefoot can increase the risk of injury to the feet, which can be particularly dangerous in individuals with PVD due to poor circulation. Any injuries to the feet may heal poorly and can lead to complications such as ulcers or infections.
Choice B reason : Using a thermometer to check the temperature of bath water is a recommended practice for clients with PVD. Due to potential nerve damage and reduced sensation in the extremities, clients may not accurately gauge water temperature, leading to burns. Therefore, using a thermometer helps prevent thermal injury.
Choice C reason : Wearing stockings with elastic tops is not recommended for clients with PVD. Elastic tops can constrict blood flow in the legs, exacerbating circulation problems. Instead, clients should wear non-constricting, well-fitting socks or stockings that promote blood flow.
Choice D reason : Avoiding crossing legs at the knees is good advice for clients with PVD. Crossing the legs can restrict blood flow to the lower extremities, which is already compromised in PVD. Keeping the legs uncrossed and elevating them when possible can help improve circulation.
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