A client who was discharged 3 days ago after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen left lower leg. The nurse is preparing to initiate heparin therapy. Which additional intervention should the nurse include in this client's plan of care?
Maintain the client on bedrest.
Administer the client's routine daily aspirin.
Encourage a diet high in iron and ascorbic acid.
Encourage the client to dangle the legs frequently.
The Correct Answer is A
A. Maintain the client on bedrest: The client’s symptoms are consistent with deep vein thrombosis (DVT). Bedrest with limited movement prevents dislodgment of the clot, which could otherwise travel to the lungs and cause a pulmonary embolism. This is the safest initial intervention while anticoagulation is being started.
B. Administer the client's routine daily aspirin: Aspirin has antiplatelet effects but is not the treatment of choice for acute DVT. Starting aspirin with heparin therapy is not recommended, as it increases the risk of bleeding without additional therapeutic benefit.
C. Encourage a diet high in iron and ascorbic acid: While iron and vitamin C support red blood cell production, this dietary intervention does not address the acute management of a thrombus. It may be useful in anemia prevention but is not a priority here.
D. Encourage the client to dangle the legs frequently: Dangling the legs promotes venous stasis and may worsen the clot or increase the risk of embolization. Clients with DVT should avoid activities that increase venous pooling until cleared by the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["18"]
Explanation
Calculation:
- Convert the client's weight from pounds (lb) to kilograms (kg).
The client's weight is 220 lb.
Client weight (kg) = 220lb/2.2lb/kg
= 100kg.
- Calculate the total heparin dose to be administered per hour (units/hr).
The ordered rate is 18 units/kg/hour.
Total dose rate (units/hr) = 18units/kg/hour×100kg
= 1800units/hr.
- Determine the concentration of the available solution (units/mL).
Available solution is 25,000units in 250mL.
Concentration (units/mL) = 25,000units/250mL
= 100units/mL.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Totaldoserate(units/hr)/Concentration(units/mL)
= 1800units/hr/100units/mL
= 18mL/hr.
Correct Answer is ["A","C","E"]
Explanation
Rationale for correct choices:
• Pain level presently 3 on a 0 to 10 scale: A reduction in pain from 8/10 to 3/10 indicates that the morphine is effectively alleviating the client’s pain. Effective analgesia allows for improved comfort, participation in breathing exercises, and reduced stress response.
• Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer: Increased inspiratory volume demonstrates improved lung expansion, indicating that pain control is facilitating better respiratory effort. This is especially important to prevent atelectasis and maintain adequate oxygenation after rib fractures.
• Repositions in bed with minimal assistance: Ability to move with less assistance reflects improved comfort and mobility due to effective pain management. This shows the therapeutic effect of analgesia in enabling functional activity without excessive pain.
Rationale for incorrect choices:
• Client reports feeling "sleepy": Sleepiness is a common side effect of morphine, reflecting central nervous system depression rather than a therapeutic effect of pain relief. While mild sedation can accompany effective analgesia, it does not directly indicate improvement in the underlying condition.
• New mild cough noted: The appearance of a new cough is not a direct indicator of therapeutic pain relief. It may reflect airway irritation, increased secretions, or a response to deeper breathing, but it is not a measure of analgesic effectiveness.
• Attempted to get up to the chair, but experienced dizziness with standing: Dizziness indicates a side effect of the opioid (orthostatic hypotension or sedation), not a therapeutic response. This finding requires monitoring and safety interventions.
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