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 A

Explanation

A. A report of chest pain is an adverse effect of epinephrine, which can increase myocardial oxygen demand and cause angina or myocardial ischemia.

B. Hypotension is not a common effect after administering epinephrine; it typically causes hypertension due to vasoconstriction.

C. Ecchymosis is not a known adverse effect of epinephrine and may be related to other factors.

D. Tinnitus is not a recognized adverse effect of epinephrine and does not commonly occur after administration.

A. Restrict visits from young children to 2 hr per day. B. Avoid including raw fruits in the client's diet. C. Measure the client's temperature every 8 hr. D. Use disposable gloves from a box outside the client's room.

Correct Answer is B

Explanation

A. While restricting visits from young children may help reduce infection risk, it is not a sufficient or specific intervention for neutropenic precautions.

B. Avoiding raw fruits is critical because they can harbor bacteria and increase the risk of infection in neutropenic clients. Cooked fruits are safer options.

C. Measuring temperature should occur more frequently than every 8 hours, ideally every 4 hours or more, to quickly identify fever, a sign of infection.

D. Disposable gloves should be used from within the client's room to maintain strict infection control measures; using gloves from outside could introduce contaminants.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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