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
Maintaining nasal packing is important after a hypophysectomy, especially if the surgery was performed through the nose (transnasal). However, it is not the most important intervention for a patient with Cushing’s disease in the post-anesthesia care unit (PACU)4.
Choice B rationale
Monitoring intake and output is a standard nursing intervention in the PACU. It helps assess the patient’s fluid balance and kidney function. However, it is not the most important intervention for a patient with Cushing’s disease following a hypophysectomy.
Choice C rationale
Providing frequent oral care is important for patient comfort and prevention of infections, but it is not the most important intervention for a patient with Cushing’s disease in the PACU following a hypophysectomy.

Choice D rationale
Keeping the head of the bed elevated to 30 degrees is the most important intervention for a patient with Cushing’s disease in the PACU following a hypophysectomy. This position helps reduce swelling, decreases the risk of aspiration, and promotes effective breathing and drainage.

A. Reassure that this can be a normal post-surgical sensation. B. Guide in moving the non-affected limb to override the sensation being experienced. C. Explain that the sensations of tingling and pain are not real. D. Affirm that a prosthetic with physical therapy will gradually improve the symptoms.

Correct Answer is A

Explanation

Choice A rationale
Reassuring the adolescent that experiencing phantom limb pain can be a normal post-surgical sensation is the correct choice. Phantom limb pain is a common occurrence after amputation and can be very distressing for the patient. The nurse should validate the patient’s experience and provide reassurance. Non-pharmacological interventions such as mirror therapy, visualization, and other cognitive-behavioral strategies can also be helpful.

Choice B rationale
Guiding the patient in moving the non-affected limb to override the sensation being experienced is not the most appropriate intervention. While some therapies for phantom limb pain involve focusing on the remaining limb, this should be done under the guidance of a trained therapist.

Choice C rationale
Telling the patient that the sensations of tingling and pain are not real is not an appropriate intervention. Although the limb is no longer there, the pain that the patient is experiencing is very real. It is important to validate the patient’s experience and provide appropriate interventions.

Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is not the most appropriate intervention. While using a prosthetic and engaging in physical therapy can help with overall recovery and adaptation after amputation, they do not directly address phantom limb pain. The pain is a result of mixed signals from the brain and nerves, and it requires specific interventions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is monitoring a patient with Cushing’s disease in the post-anesthesia care unit (PACU) following a hypophysectomy. Which intervention is most important for the nurse to include in the patient’s plan of care?

Correct Answer is D

Explanation

The nurse is providing postoperative care for an adolescent who underwent a left leg amputation due to osteosarcoma. The adolescent reports experiencing phantom limb pain. Which non-pharmacological intervention should the nurse provide?

Correct Answer is A

Explanation

A nurse is preparing a 50 mL dose of 50% dextrose IV for a patient experiencing insulin shock. What is the best method for administering the medication?

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The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility. Which outcome statement should the nurse include in the plan of care?

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?