The nurse has reviewed the Provider Prescriptions at 1600.

Exhibits
Which of the following interventions should the nurse implement for the client with deep vein thrombosis? Select all that apply.

Encourage the client to elevate their legs while in bed.

Place an immobilizer on the affected leg.

Implement bleeding precautions.

Apply intermittent pneumatic compression devices to the unaffected leg.

Instruct the client to expect dark stools.

Answer and Explanation

Correct Answer : A,C,D

Rationale:

A. Encourage the client to elevate their legs while in bed: Elevating the affected leg helps reduce venous pressure, decreasing edema and discomfort associated with DVT. Elevation also promotes venous return, which can limit further clot propagation. This intervention provides symptom relief without increasing the risk of embolization.

B. Place an immobilizer on the affected leg: Immobilizers restrict movement and are used for musculoskeletal injuries, not for DVT management. Immobilization can worsen venous stasis by reducing circulation in the lower extremity. Instead, clients with DVT benefit from gentle mobility once anticoagulation is initiated, unless contraindicated, to prevent worsening clot burden.

C. Implement bleeding precautions: The client has diagnostic confirmation of DVT and will require anticoagulation, which increases bleeding risk. Bleeding precautions help prevent complications such as hematuria, bruising, or gastrointestinal bleeding. Monitoring for signs of bleeding and avoiding trauma are essential once therapy begins.

D. Apply intermittent pneumatic compression devices to the unaffected leg: IPC devices should not be applied to the affected limb due to the risk of dislodging the thrombus. However, using them on the unaffected leg promotes venous return and helps prevent additional clot formation.

E. Instruct the client to expect dark stools: Dark stools can indicate gastrointestinal bleeding, which is not an expected effect of DVT treatment. While anticoagulants can increase bleeding risk, the nurse should teach the client to report black or tarry stools immediately.

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Correct Answer is D

Explanation

Rationale:

A. "Store oxygen cylinders on their side.": Oxygen cylinders should always be stored upright and secured to prevent tipping, rolling, or falling, which could damage the valve and create a fire hazard. Storing cylinders on their side increases the risk of accidents and is unsafe in the home setting.

B. "Use two-prong electrical outlets in the room where oxygen is used.": Electrical safety requires that outlets and devices used near oxygen be in good condition and free of sparks. The number of prongs is not the key concern; rather, all electrical equipment should be properly grounded and well-maintained to prevent ignition in an oxygen-rich environment.

C. "You can adjust the flow of your oxygen as needed.": Oxygen flow should only be adjusted according to the provider’s prescription. Changing the flow without guidance can result in hypoxia if decreased or oxygen toxicity if increased, making this statement unsafe and incorrect.

D. "Notify your power company that oxygen is used in the home.": Informing the power company is an important safety measure because home oxygen use increases fire risk. Utility companies can provide guidance on electrical safety, and emergency responders will be aware of the presence of oxygen in case of power outages or accidents.

A. "Why did you start drinking alcohol?" B. "Does anyone else in your family have a drinking problem?" C. "How old were you when you started to drink alcohol?" D. "How often do you drink alcohol?”

Correct Answer is D

Explanation

Rationale:

A. "Why did you start drinking alcohol?": This question explores motivations or personal history but is not part of the standardized Alcohol Use Disorders Identification Test (AUDIT). The AUDIT focuses on quantity, frequency, and consequences of alcohol use rather than reasons for drinking.

B. "Does anyone else in your family have a drinking problem?": Family history of alcohol use may be relevant for overall assessment but is not included in the AUDIT, which is designed to screen the client’s own drinking behaviors and risks.

C. "How old were you when you started to drink alcohol?": Age of initiation provides background information but is not a question within the AUDIT. The test is concerned with current patterns and consequences of alcohol consumption.

D. "How often do you drink alcohol?": This question is a standard component of the AUDIT and assesses the frequency of alcohol consumption. It helps identify patterns of use and potential risk for alcohol-related problems, making it appropriate for inclusion in the screening.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

The nurse has reviewed the Provider Prescriptions at 1600. Exhibits Which of the following interventions should the nurse implement for the client with deep vein thrombosis? Select all that apply.

Nursing Test Bank

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Explanation

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Explanation

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The nurse has reviewed the Provider Prescriptions at 1600.

Exhibits
Which of the following interventions should the nurse implement for the client with deep vein thrombosis? Select all that apply.