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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Ask the chaplain to discuss death issues with the client: While spiritual support may be helpful, this does not address the client’s expressed conflict about continuing treatment to satisfy his family’s wishes.

B. Notify the family that treatments have been discontinued: The nurse cannot make the decision to discontinue treatments without the client’s and healthcare provider’s input. This would be outside the nurse’s scope of authority.

C. Request a consultation with the hospital social worker: Although a social worker can help with emotional support and end-of-life planning, the immediate concern is facilitating open communication between the client, family, and healthcare team about the client’s wishes.

D. Arrange a meeting with the family, healthcare provider, and client: This action supports the client’s autonomy and ensures his wishes are heard. It also promotes collaborative decision-making about continuing or stopping treatment, aligning care with the client’s goals and values.

A. Soft abdomen, absent bowel sounds, no bleeding on dressing. B. Peripheral pulses present with full range of motion of both legs. C. Declining to take ice chips despite reporting of dry mouth. D. History of vomiting at home for 3 days prior to surgery.

Correct Answer is D

Explanation

A. Soft abdomen, absent bowel sounds, no bleeding on dressing: This provides relevant post-operative assessment information, but it reflects the current status rather than additional history affecting immediate care priorities.

B. Peripheral pulses present with full range of motion of both legs: This is important for neurovascular assessment, but it is already covered in routine PACU reporting and does not represent additional critical information.

C. Declining to take ice chips despite reporting of dry mouth: While this may affect hydration and comfort, it does not significantly alter immediate post-operative management and can be addressed by the receiving nurse.

D. History of vomiting at home for 3 days prior to surgery: This is significant additional information because prolonged preoperative vomiting can lead to fluid and electrolyte imbalances, increasing the risk for complications post-operatively. The receiving nurse needs to be aware to guide monitoring and interventions.

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Naxlex Comprehensive Predictor Exams

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client verbalizes that he is tired of fighting this illness and is only continuing treatments because his family wants him to live. Which action should the nurse take?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

A client diagnosed with glaucoma receives a new prescription for dorzolamide. Prior to administering the medication, the nurse should review the electronic medical record for which allergy?

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