The nurse has reviewed the Provider Prescriptions at 1600.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. “Our children can stay up as late as they prefer.” This statement reflects a permissive parenting style, where few rules are enforced and children have significant freedom. Parents in this style often avoid setting firm boundaries, which contrasts sharply with the strict control seen in authoritarian parenting.
B. “Our children are allowed to make their own choices.” This reflects an authoritative parenting style, which balances independence with guidance. Authoritative parents encourage decision-making while still providing consistent rules and support. This collaborative, approach differs significantly from the rigid and demanding nature of authoritarian parenting.
C. “We make decisions as a family.” This statement also aligns with authoritative parenting, which values communication, mutual respect, and shared problem-solving. Children’s input is considered, helping them develop confidence and reasoning skills. Such family-centered decision-making is not present in authoritarian households.
D. “We expect our children to do what we say without any questions.” Authoritarian parenting focuses on obedience, strict rules, and limited negotiation. Children are expected to comply without explanation, and parents often enforce discipline rigidly. This style places emphasis on control rather than communication.
Correct Answer is C
Explanation
Rationale:
A. Increase the rate of the oxytocin infusion: Increasing oxytocin would intensify uterine contractions, which can worsen uteroplacental insufficiency and exacerbate late decelerations. This action is unsafe and contraindicated when late decelerations are present.
B. Administer dinoprostone transvaginally: Dinoprostone is used to ripen the cervix or induce labor, not to correct fetal distress caused by uteroplacental insufficiency. Administering it in this scenario would not address the underlying problem and could increase fetal risk.
C. Place the client in a lateral position: Lateral positioning improves uteroplacental blood flow and oxygen delivery to the fetus, which can reduce late decelerations. It is an immediate, safe, and effective nursing intervention to relieve fetal stress caused by decreased placental perfusion.
D. Assist the client to empty their bladder: While bladder distention can affect uterine contractions and comfort, it does not directly address late decelerations. Emptying the bladder may be beneficial for other reasons, but repositioning the client takes priority in improving fetal oxygenation.
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