A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?

Elevate the affected leg.

Place cold compresses on the edematous area.

Restrict the client to 1 L of fluid per day.

Maintain the client on bed rest.

Answer and Explanation

The Correct Answer is A

A. Elevating the affected leg is an important intervention for reducing swelling and promoting venous return, which can help alleviate discomfort and prevent further complications.

B. Placing cold compresses on the edematous area may provide temporary relief but is not a standard intervention for deep-vein thrombosis and could potentially harm tissue if applied for too long.

C. Restricting the client to 1 L of fluid per day is inappropriate, as adequate hydration is essential for maintaining good venous health and preventing further complications.

D. Maintaining the client on bed rest is not necessary; while rest is important, early ambulation is encouraged to promote circulation and prevent further clot formation unless contraindicated.

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Correct Answer is C

Explanation

A. Compensated metabolic acidosis would show a normal pH with a decrease in HCO3- and a decrease in PaCO2.

B. Compensated respiratory acidosis would show a normal pH with an elevated PaCO2 and a compensatory increase in HCO3-.

C. The low pH indicates acidosis, and the elevated PaCO2 suggests that it is respiratory in origin, with the HCO3- remaining normal, indicating no compensation has occurred yet.

D. Uncompensated metabolic acidosis would present with a low pH, low HCO3-, and normal PaCO2.

A. Apply a cold compress to the affected extremity. B. Teach the client to massage the affected extremity. C. Instruct the client to elevate the affected extremity when sitting. D. Assess pulses proximal to the affected area.

Correct Answer is C

Explanation

A. Applying a cold compress is not recommended for DVT; instead, heat may be more appropriate to alleviate discomfort and improve circulation.

B. Massaging the affected extremity is contraindicated as it can dislodge the clot and lead to complications such as pulmonary embolism.

C. Instructing the client to elevate the affected extremity helps reduce swelling and promote venous return, making it the best action.

D. Assessing pulses proximal to the affected area is important for monitoring circulation, but it is not the primary intervention for managing DVT.

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A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left 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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