A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol.
Which intervention is most important for the nurse to include in this client’s plan of care?

Observe for bleeding side effects related to heparin therapy.

Encourage mobilization to prevent pulmonary embolism.

Assess blood pressure and heart rate at least every 4 hours.

Measure each calf’s girth to evaluate edema in the affected leg.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Heparin is an anticoagulant medication that prevents the formation of blood clots. One of the most common and serious side effects of heparin therapy is bleeding. Therefore, it is crucial for the nurse to observe for signs of bleeding, such as bruising, petechiae, hematomas, black tarry stools, hematuria, and changes in mental status. Regular laboratory monitoring of the client’s coagulation status, specifically the activated partial thromboplastin time (aPTT), is also necessary to ensure therapeutic levels of heparin without causing excessive bleeding.

Choice B rationale

While mobilization can help prevent the formation of new clots, it is not the most important intervention for a client who is already on a heparin protocol for DVT. Mobilization can potentially dislodge the existing clot, leading to a life-threatening pulmonary embolism.

Choice C rationale

Although it is important to monitor vital signs in all clients, assessing blood pressure and heart rate every 4 hours is not the most important intervention for a client on a heparin protocol.

Changes in blood pressure and heart rate are not specific to heparin therapy and do not provide direct information about the effectiveness or side effects of the medication.

Choice D rationale

Measuring each calf’s girth can help evaluate the progression of edema in the affected leg, but it is not the most important intervention for a client on a heparin protocol. While it can provide information about the local effects of the DVT, it does not address the systemic anticoagulation effects of heparin therapy.

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Correct Answer is A

Explanation

Choice A rationale

Initiating a hearing and vision screening program for first graders is an example of secondary prevention. Secondary prevention aims to identify and treat an illness or disease at an early stage, which is exactly what a screening program does.

Choice B rationale
Observing a person with type I diabetes mellitus self-administer a dose of insulin is not an example of secondary prevention. This is more related to disease management, which falls under tertiary prevention.

Choice C rationale
Preparing a presentation on how to prevent the spread of lice is an example of primary prevention, which aims to prevent disease or injury before it ever occurs.

Choice D rationale
Collaborating with a science teacher to prepare a health lesson could be seen as primary prevention if the lesson is about preventing disease, or tertiary prevention if it’s about managing existing conditions.

A. Productive cough B. Respiratory rate of 28 breaths/minute C. Oxygen saturation of 90% on room air D. Heart rate of 101 beats/minute E. Capillary refill of 4 seconds F. Blood pressure of 145/89 mm Hg

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale
A productive cough is not a specific indicator of hypoxia. It could be a symptom of many conditions, including a common cold, flu, or other respiratory tract infections.
Choice B rationale

A respiratory rate of 28 breaths/minute is higher than the normal range (12-20 breaths/minute for adults), indicating that the patient may be trying to increase oxygen intake and eliminate carbon dioxide due to hypoxia.
Choice C rationale
An oxygen saturation of 90% on room air is lower than the normal range (95%-100%). This indicates that the patient’s blood is not carrying as much oxygen as it should, which is a sign of hypoxia.
Choice D rationale
A heart rate of 101 beats/minute is higher than the normal range (60-100 beats/minute for adults). This could be a response to hypoxia as the body tries to deliver more oxygen to the tissues.
Choice E rationale
A capillary refill of 4 seconds is slightly longer than the normal range (less than 2 seconds). While this could indicate poor peripheral circulation, it is not a specific or direct indicator of hypoxia.
Choice F rationale
A blood pressure of 145/89 mm Hg is higher than the normal range (less than 120/80 mm Hg). While hypertension could be related to many factors, it is not a specific indicator of hypoxia.

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A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

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Naxlex Comprehensive Predictor Exams

What action should the school nurse take to provide secondary prevention for school-aged children?

Correct Answer is A

Explanation

Correct Answer is ["B","C","D"]

Explanation

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A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol.
Which intervention is most important for the nurse to include in this client’s plan of care?