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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Leave the television on as a distraction – Noise and distractions can increase anxiety and confusion in some patients.
B. Limit patient physical activity – Regular exercise is essential to maintain mobility and prevent muscle atrophy.
C. Provide patient supervision – Clients with Parkinson’s disease are at high risk for falls due to muscle rigidity and balance difficulties. Supervision ensures safety and helps prevent injuries.
D. Speak loudly to the patient – Parkinson’s does not typically cause hearing loss. Speaking clearly and slowly is more effective than speaking loudly.
Correct Answer is C
Explanation
A. Inserting an indwelling urinary catheter – Incorrect. While catheterization may be necessary, it is not the highest priority for an unconscious patient.
B. Putting a nasogastric (NG) tube in place – Incorrect. NG tube placement can be useful for feeding or decompressing the stomach, but airway management takes precedence.
C. Maintaining a patent airway – Correct Answer. Airway patency is the top priority in an unconscious patient to prevent aspiration, hypoxia, or respiratory failure.
D. Administering an enema daily – Incorrect. This is not a priority in unconscious patients.
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