The nurse is developing a plan of care for a client who will be admitted to the medical-surgical unit with a diagnosis of deep vein thrombosis (DVT) of the right leg. What should be included in the client's care plan?

Administer an opioid analgesic every 4 hours around the clock.

Frequently measure the client's calf circumference and compare the client's baseline measurement.

Apply cool packs to the affected leg for 20 minutes every 4 hours.

Maintain the affected leg in a dependent position.

Answer and Explanation

The Correct Answer is B

A. Opioid analgesics may be necessary for pain but are not the priority in DVT management.

B. Measuring calf circumference regularly helps monitor for swelling or worsening of the DVT.

C. Cool packs are not recommended for DVT; warm compresses may be used for comfort, but anticoagulation therapy is the main treatment.

D. The affected leg should be elevated, not kept in a dependent position, to promote venous return and reduce swelling.

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Correct Answer is A

Explanation

A. The Snellen chart is the standard tool used to assess distant vision.

B. An otoscope is used to examine the ears, not vision.

C. A penlight is used for pupillary responses and not for vision testing.

D. The Rinne test assesses hearing, not vision.

A. Heart murmurs (S3, S4) B. Breath sounds C. Normal heart (S1,S2) D. Bowel sounds

Correct Answer is A

Explanation

A. The bell of the stethoscope is used to detect low-pitched sounds such as heart murmurs (S3 and S4).

B. Breath sounds are typically auscultated using the diaphragm of the stethoscope.

C. Normal heart sounds (S1, S2) are best heard using the diaphragm of the stethoscope.

D. Bowel sounds are auscultated using the diaphragm, not the bell.

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The nurse is developing a plan of care for a client who will be admitted to the medical-surgical unit with a diagnosis of deep vein thrombosis (DVT) of the right leg. What should be included in the client's care plan?

Nursing Test Bank

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Explanation

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