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 D

Explanation

Choice A rationale
Urinating only once or twice a day is not a typical symptom of type I diabetes mellitus. In fact, frequent urination is a common symptom of diabetes.
Choice B rationale
Rapid weight gain is not typically associated with type I diabetes mellitus. On the contrary, unexplained weight loss is a common symptom.
Choice C rationale
Refusing to eat favorite meals is not a typical symptom of type I diabetes mellitus. Changes in appetite can occur in various conditions, but they are not specific to diabetes.
Choice D rationale
Drinking more fluids than usual, also known as polydipsia, is a common symptom of type I diabetes mellitus. This is often accompanied by polyuria (frequent urination) due to high blood sugar levels.

A. Check blood sugar levels every four to six hours every day. B. Keep diabetic medication on schedule as prescribed. C. Restrict alcoholic beverages to no more than 1-2 per week. D. Limit maximum daily fat intake to 15% of total calories.

Correct Answer is B

Explanation

Choice A rationale
While regular monitoring of blood sugar levels is important in managing diabetes, checking every four to six hours every day may not be necessary for all patients. The frequency of blood glucose monitoring should be individualized based on the type and severity of the diabetes, the patient’s blood glucose control, and the patient’s specific needs.
Choice B rationale

Keeping diabetic medication on schedule as prescribed is crucial in managing blood glucose levels and preventing complications related to diabetes. This indicates that the patient has understood the importance of medication adherence in diabetes management.
Choice C rationale
While it’s recommended to limit alcohol consumption, restricting alcoholic beverages to no more than 1-2 per week is not a standard guideline for all patients with diabetes. The effects of alcohol on blood glucose levels can vary depending on several factors, including the amount of alcohol consumed, the presence of food, and the individual’s overall diabetes management.
Choice D rationale
Limiting daily fat intake to 15% of total calories is not a standard recommendation for patients with diabetes. The American Diabetes Association recommends individualized medical nutrition therapy to manage diabetes, which may include monitoring carbohydrate intake and considering the quality of fats and proteins in the diet.

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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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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?