A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?
Monitor for bleeding side effects related to heparin therapy.
Promote movement to prevent a pulmonary embolism.
Check blood pressure and heart rate at least every 4 hours.
Measure the circumference of each calf to assess for leg edema.
The Correct Answer is A
Choice A rationale
The most crucial intervention for a nurse to include in the care plan of a client with a deep vein thrombosis (DVT) in the left leg who is on a heparin protocol is to monitor for bleeding side effects related to heparin therapy. Heparin is an anticoagulant medication that prevents the formation of blood clots. While it is an effective treatment for DVT, it can also increase the risk of bleeding. Therefore, it is essential for the nurse to closely monitor the client for any signs of bleeding, such as unusual bruising, blood in urine or stool, or bleeding gums.
Choice B rationale
While promoting movement can help prevent a pulmonary embolism (a potential complication of DVT), it is not the most crucial intervention when a client is on a heparin protocol. Excessive movement can potentially dislodge the clot, leading to a pulmonary embolism. Therefore, while movement is important, it should be done under the guidance of a healthcare professional.
Choice C rationale
Checking blood pressure and heart rate at least every 4 hours is a standard nursing intervention for many clients, not just those with DVT. While it is important to monitor these vital signs, it is not the most crucial intervention for a client with DVT on a heparin protocol.
Choice D rationale
Measuring the circumference of each calf can help assess for leg edema, which can be a sign of DVT. However, this is not the most crucial intervention for a client on a heparin protocol. The priority is to monitor for bleeding side effects related to the heparin therapy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Encouraging the client to participate in a team sport for one hour might be beneficial for the client’s physical health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice B rationale
Assisting the client in developing a list of daily affirmations can be a helpful strategy for improving self-esteem and promoting positive thinking, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice C rationale
Scheduling the client for a group session that focuses on self-esteem can be beneficial for the client’s mental health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice D rationale
Helping the client in identifying goals for the day can be a very effective intervention for a client with severe depression. Setting daily goals can provide the client with a sense of purpose and can help to motivate the client to engage in activities other than sitting and watching television.
Correct Answer is ["D","E","F"]
Explanation
Choice D rationale
Involving the mother in the decision-making process can help alleviate some of the stress associated with caregiving. It allows the mother to maintain some control over her care and ensures that her needs and preferences are being met.
Choice E rationale
It is normal to have mixed feelings when caring for a loved one. Acknowledging these feelings can be an important part of managing caregiver stress.
Choice F rationale
Taking time for oneself and maintaining other relationships is crucial for caregiver well-being. It can help prevent burnout and improve the quality of care provided to the mother.
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