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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason : A hemoglobin (Hgb) level of 16 g/dL is within the normal range for adults, which typically falls between 13.8 to 17.2 g/dL for men and 12.1 to 15.1 g/dL for women. Therefore, this value does not warrant reporting to the provider as it does not indicate an immediate concern.
Choice B reason : A prothrombin time (PT) of 45 seconds is significantly higher than the normal range of 11 to 13.5 seconds for individuals not on anticoagulation therapy. For patients on warfarin, the target PT is usually 1.5 to 2 times the normal value, depending on the indication for therapy. However, a PT of 45 seconds suggests a high risk of bleeding and requires immediate medical attention.
Choice C reason : The activated partial thromboplastin time (aPTT) of 36 seconds is within the normal range of approximately 21 to 35 seconds⁸. This result indicates that the blood's intrinsic clotting pathway is functioning within expected parameters and does not need to be reported.
Choice D reason : A platelet count of 190,000/mm is within the normal range, which is typically 150,000 to 450,000 platelets/mm. This value is not concerning and does not need to be reported to the provider.
Correct Answer is C
Explanation
Choice A reason : The statement that warfarin dissolves clots in the bloodstream is incorrect. Warfarin does not dissolve existing clots. Instead, it is an anticoagulant that works by decreasing the production of certain clotting factors in the blood, which helps prevent the formation of new clots.
Choice B reason : This statement is not accurate regarding the action of warfarin. Warfarin does not affect the electrical impulses of the heart. Medications that slow the response of the ventricles to fast atrial impulses are typically antiarrhythmic drugs, not anticoagulants like warfarin.
Choice C reason : This is the correct statement. Warfarin is prescribed for clients with atrial fibrillation to reduce the risk of stroke. Atrial fibrillation increases the risk of forming blood clots in the heart, which can then travel to the brain, causing a stroke. Warfarin's anticoagulant effect helps to prevent these clots from forming.
Choice D reason : Warfarin does not help maintain a normal heart rhythm. It is not an antiarrhythmic drug but an anticoagulant. The purpose of warfarin in atrial fibrillation is to prevent stroke by reducing the risk of clot formation, not to correct the heart rhythm.
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