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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Soft, pliable calf muscle: A soft and pliable calf muscle is not indicative of a thrombus. Typically, a thrombus leads to swelling and firmness in the affected area.

B. Cool and clammy skin: Cool and clammy skin could indicate poor circulation, but it is not specific to a thrombus.

C. Dull, aching calf pain: Dull, aching calf pain is a key symptom of deep vein thrombosis (DVT) and should prompt further investigation.

D. Temperature > 100°F: A fever could indicate an infection but is not a classic sign of a thrombus.

A. Troponin T B. Creatinine phosphokinase C. Myoglobin D. Creatinine kinase-MB

Correct Answer is A

Explanation

A. Troponin T: Troponin T remains elevated for 10 to 14 days after a myocardial infarction. This protein is highly specific for cardiac muscle injury and is used to confirm myocardial infarction.

B. Creatinine phosphokinase: Creatinine phosphokinase (CPK) typically returns to normal levels within 3 days after a myocardial infarction, so it would no longer be elevated at this point.

C. Myoglobin: Myoglobin rises early after a myocardial infarction but is not specific to heart muscle and returns to normal within 24 hours, so it would not be elevated at this time.

D. Creatinine kinase-MB: Creatinine kinase-MB (CK-MB) usually returns to normal levels within 2 to 3 days after a myocardial infarction, so it is unlikely to still be elevated 6 days later.

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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?

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