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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Restricted activity can help reduce intestinal activity, thereby decreasing inflammation and allowing for tissue healing within the gastrointestinal tract.
Choice B rationale
While controlling diarrhea episodes is an important aspect of managing Crohn’s disease, it is not the primary purpose of activity restriction.
Choice C rationale
Promoting the healing process is a crucial aspect of managing Crohn’s disease. However, the primary purpose of activity restriction is to reduce intestinal activity, which in turn can promote healing.
Choice D rationale
Decreasing abdominal pain is an important aspect of managing Crohn’s disease, but it is not the primary purpose of activity restriction.
Correct Answer is A
Explanation
Choice A rationale
The unlicensed assistive personnel (UAP) is providing care to a client with influenza, a respiratory illness that can be transmitted through droplets when the client coughs or sneezes. Therefore, it is crucial for the UAP to wear a face mask while in close contact with the client to prevent the transmission of the virus. This is in line with the standard precautions for infection control, which recommend the use of personal protective equipment (PPE) such as gloves, gowns, and masks when providing care to clients with infectious diseases.
Choice B rationale
Reassigning the UAP to another client and assuming full care of the client is not the most appropriate action in this situation. While it is the nurse’s responsibility to ensure that the UAP is competent and understands the care needs of the client, it is not necessary to reassign the UAP unless there are specific concerns about their ability to provide safe and effective care.
Choice C rationale
While it is important for the UAP to alert the nurse of any changes in the client’s respiratory status, this is not the most immediate action that the nurse should take in this situation. The priority is to ensure that the UAP is wearing appropriate PPE to prevent the transmission of influenza.
Choice D rationale
A fitted respirator mask is typically used when caring for clients with airborne diseases, such as tuberculosis. Influenza is primarily spread through droplets, so a regular face mask is usually sufficient for protection.
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