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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Ankle pain after running a long distance could indicate overuse or strain, but it is more likely to suggest a muscle or tendon issue rather than a sprain.
B. Twisting the foot while running or changing direction quickly, as often happens in sports like baseball, is a common mechanism for an ankle sprain. Sprains occur when the ligaments are stretched or torn due to excessive force or twisting.
C. Being hit by another player in soccer could cause a contusion or fracture, but it is less likely to cause an ankle sprain unless there was a specific twisting or rolling of the ankle.
D. Dropping a weight on the lower leg is more likely to cause a contusion, fracture, or soft tissue injury rather than a sprain.

A. The dressing forms a cone shape over the stump B. Pitting edema around the stump dressing C. Looseness of the stump dressing D. Figure-eight wrapping around the stump

Correct Answer is B

Explanation

A. A cone-shaped dressing is a common and appropriate finding following an amputation. The dressing is typically shaped this way to help with the formation of a residual limb that is appropriately shaped for a prosthetic.
B. Pitting edema around the stump dressing is a complication. This could indicate poor circulation, infection, or fluid retention, which requires prompt assessment and intervention to prevent further complications.
C. Looseness of the stump dressing could be problematic, but it is not necessarily an immediate complication. It may lead to issues like infection or improper healing if not addressed, but it is not the most concerning finding in this scenario.
D. Figure-eight wrapping is a standard technique used to secure the dressing and promote proper shaping of the stump. It is an appropriate practice for amputation care.

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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?

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Naxlex Comprehensive Predictor Exams

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