A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?
Limit movement of the lower extremities.
Place sequential compression devices bilaterally.
Massage lower extremities daily.
Check for negative Homans' sign.
The Correct Answer is B
A. Limit movement of the lower extremities. Limiting movement increases the risk of venous stasis, which can lead to DVT. Regular movement and ambulation are encouraged to promote blood circulation.
B. Place sequential compression devices bilaterally. Sequential compression devices (SCDs) help promote venous return and prevent venous stasis, thereby reducing the risk of DVT.
C. Massage lower extremities daily. Massaging the legs is contraindicated in clients at risk for DVT because it can dislodge a clot and lead to pulmonary embolism.
D. Check for negative Homans' sign. The Homans' sign (pain in the calf on dorsiflexion of the foot) is not a reliable indicator of DVT and is no longer recommended as a standard assessment method.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["94"]
Explanation
To calculate the rate, divide the total volume to be infused by the time (in hours).
Rate =750 mL ÷ 8 hr
= 93.75 mL/hr
Rounded to the nearest whole number: 94 mL/hr.
Correct Answer is B
Explanation
A. Use the diaphragm of the stethoscope to listen to the carotid pulsations. The apical pulse is located at the apex of the heart, not at the carotid artery. This option does not describe the correct location or use of the stethoscope.
B. Count the apical pulsations for a full minute. Counting for a full minute is the correct method for assessing an apical pulse, particularly in clients on cardiovascular medications, to ensure accurate detection of any irregularities.
C. Check the apical pulse with a Doppler device. A Doppler device is typically used to assess peripheral pulses, not the apical pulse. A stethoscope is the appropriate tool for apical pulse assessment.
D. Press the stethoscope firmly against the client's skin. While the stethoscope should be placed firmly enough to hear heart sounds, excessive pressure can distort the sounds and is not necessary.
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