The nurse is caring for a client with a history of deep vein thrombosis. Which intervention should the nurse include in the care plan?

Encourage early ambulation

Apply warm compresses to the leg

Restrict fluid intake

Elevate the affected leg

Answer and Explanation

The Correct Answer is D

Choice A reason: Early ambulation prevents stasis but is contraindicated in acute deep vein thrombosis, as it risks dislodging the clot, causing pulmonary embolism. Leg elevation reduces swelling and promotes venous return, making it the priority intervention to manage acute DVT safely.

Choice B reason: Warm compresses may increase blood flow but are not standard for deep vein thrombosis, as they risk clot dislodgement. Leg elevation reduces edema and venous pressure, improving circulation without mobilizing the clot, making it the preferred intervention for DVT management.

Choice C reason: Restricting fluid intake is inappropriate, as hydration prevents blood viscosity increases that exacerbate deep vein thrombosis. Leg elevation directly reduces swelling and promotes venous return, addressing the primary issue of venous stasis, making it the priority over fluid restriction.

Choice D reason: Elevating the affected leg reduces edema and venous pressure in deep vein thrombosis by promoting venous return to the heart. This decreases clot propagation risk and alleviates pain, making it a key intervention to manage acute DVT effectively and prevent complications.

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Correct Answer is A

Explanation

Choice A reason: Sexual dysfunction is a common SSRI side effect, as increased serotonin inhibits sexual arousal and orgasm. Monitoring is critical, as it affects adherence in depression treatment, requiring dose adjustments or alternative therapies, making it the priority side effect to assess.

Choice B reason: Hypotension is less common with SSRIs, though orthostatic changes may occur. Sexual dysfunction is more frequent, impacting quality of life and treatment adherence in depression, making it the priority to monitor, as it directly affects patient compliance and outcomes.

Choice C reason: Hyperglycemia is not a typical SSRI side effect, though metabolic changes are rare. Sexual dysfunction is a prevalent issue, reducing adherence in depression treatment, making it the priority to monitor, as it significantly impacts patient satisfaction and therapy continuation.

Choice D reason: Peripheral edema is rare with SSRIs, which primarily affect serotonin pathways. Sexual dysfunction is a common side effect, compromising adherence in depression management, making it the priority to monitor, as it directly influences treatment success and patient well-being.

A. Replace the gauze with a transparent dressing B. Apply a hydrocolloid gel dressing C. Leave the dressing off until consulting with the healthcare provider D. Increase the frequency of the dressing changes

Correct Answer is B

Explanation

Choice A reason: Transparent dressings are semi-permeable, suitable for superficial wounds with minimal exudate. Stage 3 pressure injuries, with deeper tissue damage and granulation, require moisture-retentive dressings to support healing. Transparent dressings may not provide the moist environment needed for optimal granulation tissue formation and epithelialization in deeper wounds.

Choice B reason: Hydrocolloid gel dressings maintain a moist wound environment, ideal for stage 3 pressure injuries with granulation tissue. They promote autolytic debridement, support epithelialization, and protect the wound. This is the best choice, as gauze may adhere to granulation tissue, causing trauma during removal, unlike hydrocolloids, which foster healing.

Choice C reason: Leaving the dressing off exposes the wound to infection and drying, which impairs granulation tissue and delays healing. Stage 3 pressure injuries require a moist, protected environment. Consulting the provider may be appropriate for complex cases, but immediate dressing application is standard to maintain optimal wound conditions.

Choice D reason: Increasing dressing change frequency may disrupt granulation tissue and delay healing, especially with gauze, which can adhere to the wound bed. Stage 3 pressure injuries benefit from stable, moist environments provided by advanced dressings like hydrocolloids, not frequent changes that risk trauma and infection.

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The nurse is caring for a client with a history of deep vein thrombosis. Which intervention should the nurse include in the care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of depression who is prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect should the nurse monitor for?

Correct Answer is A

Explanation

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is B

Explanation

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