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. According to the recommended dosage range of 20 to 25 mg/kg/day for a toddler weighing 20 kg, the daily dosage should be between 400 mg (20 kg x 20 mg) and 500 mg (20 kg x 25 mg). Therefore, the prescribed dosage of 300 mg/day is below the recommended range.

B. The nurse determines the prescription is above the recommended dosage range. This is incorrect because the prescribed dosage is actually below the recommended range.

C. The nurse contacts the pharmacist to adjust the prescribed dosage. This would be an appropriate action since the prescribed dosage does not meet the recommended range, and collaboration with the pharmacist could ensure the correct dosage is administered.

D. The nurse administers the prescribed dosage. This would not be appropriate without first addressing the discrepancy between the prescribed dosage and the recommended range.

A. Oxygen saturation level 96% B. Respiratory alkalosis C. Petechiae on chest D. Increased anteroposterior diameter of the chest

Correct Answer is D

Explanation

A. Clients with COPD often have low oxygen saturation levels; an oxygen saturation of 96% is not typical.

B. Respiratory acidosis, not alkalosis, is more common in clients with COPD due to the retention of carbon dioxide.

C. Petechiae on the chest is not commonly associated with COPD or emphysema.

D. An increased anteroposterior diameter of the chest, often referred to as a "barrel chest," is a common physical finding in clients with emphysema due to lung hyperinflation.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer amoxicillin 100 mg PO every 8 hr to a toddler who weighs 20 kg. The recommended dosage range is 20 to 25 mg/kg/day. Which action by the nurse is appropriate?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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