A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?
Apply ice packs to affected leg.
Keep the client's affected leg elevated while in bed.
Have the client ambulate prior to applying antiembolic stockings.
Massage the client's affected leg twice a day.
The Correct Answer is B
A. Apply ice packs to affected leg: While ice can help reduce swelling and pain in some conditions, it is not typically recommended for deep vein thrombosis (DVT) because it could increase the risk of clot dislodgement.
B. Keep the client's affected leg elevated while in bed: Elevating the leg helps reduce swelling and promotes venous return, which is important in managing DVT.
C. Have the client ambulate prior to applying antiembolic stockings: Ambulation is usually avoided initially in the presence of DVT until anticoagulation therapy is started to reduce the risk of clot dislodgement. Antiembolic stockings should be applied after anticoagulation therapy is initiated.
D. Massage the client's affected leg twice a day: Massaging the affected leg is contraindicated in DVT as it can increase the risk of dislodging the clot, leading to complications such as pulmonary embolism.
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Related Questions
Correct Answer is C
Explanation
A. Ascites is the accumulation of fluid in the peritoneal cavity, often due to liver disease such as cirrhosis. It does not directly cause the formation of biliary sludge, which is related to bile composition and flow.
B. Biliary colic refers to pain caused by the gallbladder's inability to expel bile, often due to a gallstone blocking the bile duct. While biliary colic may be associated with gallstones, it is not the primary cause of biliary sludge.
C. Bile stasis is the primary cause of biliary sludge. It occurs when bile remains in the gallbladder for an extended period, leading to the formation of thickened bile and sludge. Factors such as fasting, pregnancy, or liver disease can contribute to bile stasis.
D. Hepatitis is an inflammation of the liver, which may affect bile production but does not directly cause biliary sludge. Hepatitis can lead to other complications such as jaundice but is not the main cause of biliary sludge formation.
Correct Answer is D
Explanation
A. Bicarbonate is important to monitor in conditions like metabolic acidosis or alkalosis, but it is not the primary laboratory value to monitor for a client on furosemide.
B. Albumin levels are important to monitor for nutritional status or liver function but are not directly impacted by furosemide use.
C. Cortisol levels are not typically affected by furosemide. Cortisol is more relevant in conditions like Cushing's syndrome or adrenal insufficiency.
D. Potassium is the primary laboratory value to monitor when a client is on furosemide, a loop diuretic. Furosemide increases the excretion of potassium, which can lead to hypokalemia. This can cause serious cardiac and muscular complications, so regular monitoring of potassium levels is crucial.
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