A patient with spinal cord injury has altered-mobility, which increases the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent DVT formation?

Applying a sequential compression device

Administering an antifibrinolytic agent

Placing the patient on a fluid restriction

Assisting the patient with passive ROM exercises

Answer and Explanation

The Correct Answer is A

A. Applying a sequential compression device. – Correct Answer. SCDs help prevent venous stasis, reducing the risk of DVT in immobile patients.

B. Administering an antifibrinolytic agent. – Incorrect. Antifibrinolytics promote clot formation and are used for bleeding disorders, not DVT prevention.

C. Placing the patient on a fluid restriction. – Incorrect. Adequate hydration is important to prevent blood viscosity and clot formation.

D. Assisting the patient with passive ROM exercises. – Incorrect. Passive ROM helps circulation, but SCDs provide more effective DVT prevention.

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Correct Answer is D

Explanation

A. Dextrose 5% in 0.45% sodium chloride IV. – Incorrect. Dextrose is given later, after blood glucose drops below 250 mg/dL to prevent hypoglycemia.

B. Oral hypoglycemic medications. – Incorrect. DKA requires IV insulin, not oral medications.

C. Glucocorticoid medications. – Incorrect. Glucocorticoids can worsen hyperglycemia by increasing blood sugar.

D. 0.9% sodium chloride IV. – Correct Answer. Fluid resuscitation with normal saline is the first priority to correct hypovolemia caused by osmotic diuresis in DKA.

A. 8 hr B. 6 hr C. 4 hr D. 2 hr

Correct Answer is C

Explanation

A. 8 hr – Incorrect. RBC transfusions must not exceed 4 hours due to the risk of bacterial growth and hemolysis.

B. 6 hr – Incorrect. Blood products should be infused within a maximum of 4 hours to prevent complications.

C. 4 hr – Correct Answer. The maximum infusion time for packed RBCs is 4 hours to reduce the risk of bacterial contamination and infection.

D. 2 hr – Incorrect. While blood is often infused within 2 hours, the maximum safe limit is 4 hours.

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A patient with spinal cord injury has altered-mobility, which increases the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent DVT formation?

Nursing Test Bank

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