A client with deep vein thrombosis (DVT) is prescribed anticoagulant therapy. What is the nurse's priority action in monitoring the client's response to the medication?

Assessing for changes in blood pressure.

Monitoring the client's prothrombin time (PT) and international normalized ratio (INR).

Checking the client's blood glucose levels.

Evaluating the client's respiratory rate and pattern.

Answer and Explanation

The Correct Answer is B

A) This choice is incorrect because while monitoring blood pressure is essential, it is not the priority action for clients on anticoagulant therapy. The primary concern is assessing the client's response to the medication and their risk of bleeding.

B) This choice is correct. Monitoring the client's prothrombin time (PT) and international normalized ratio (INR) is crucial in assessing the effectiveness of anticoagulant therapy. The PT and INR measure how long it takes the blood to clot and help determine the appropriate dosage of anticoagulants to achieve the desired therapeutic effect.

C) This choice is incorrect because checking the client's blood glucose levels is not directly related to monitoring the response to anticoagulant therapy. Blood glucose monitoring is essential for clients with diabetes but not a priority in this context.

D) This choice is incorrect because evaluating the client's respiratory rate and pattern is not the priority action for monitoring the response to anticoagulant therapy. Respiratory assessment is vital in detecting potential complications like a pulmonary embolism but does not directly assess the client's anticoagulation status.

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Correct Answer is A

Explanation

A) This choice is correct. Prolonged sitting or standing in one position can lead to reduced blood flow and stasis, increasing the risk of DVT. Encouraging regular movement and changing positions can help prevent clot formation.

B) This choice is incorrect because massaging the legs may not be suitable for everyone and is not a primary preventive measure for DVT. While it can aid in improving blood circulation, it should be done cautiously and not as a standalone preventive action.

C) This choice is incorrect because increasing the intake of vitamin K-rich foods is not a preventive measure for DVT. Vitamin K is involved in the clotting process, but it does not directly impact the risk of DVT.

D) This choice is incorrect because taking over-the-counter pain medications for leg discomfort does not prevent DVT. While pain management may be necessary for symptomatic relief, it does not address the underlying risk factors for DVT.

A. Advanced age B. Male gender C. Smoking history D. Hormonal therapy

Correct Answer is D

Explanation

A) This choice is incorrect because advanced age is a non-modifiable risk factor for DVT. While age is associated with increased risk, it is not directly related to the client's use of hormonal therapy.

B) This choice is incorrect because male gender is not a risk factor for DVT. Women, particularly those on estrogen-based therapies like hormone replacement therapy or oral contraceptives, are at higher risk.

C) This choice is incorrect because smoking history is a modifiable risk factor for DVT, not directly related to hormonal therapy. Smoking increases the risk of clot formation and is not specific to the client's use of hormonal therapy.

D) This choice is correct. Estrogen-based hormone replacement therapy and oral contraceptives can increase the risk of DVT due to their effect on blood coagulation. Estrogen can increase the production of certain clotting factors, raising the risk of blood clot formation in the veins. It is essential for healthcare providers to weigh the benefits and risks when prescribing hormonal therapy to clients.

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A client with deep vein thrombosis (DVT) is prescribed anticoagulant therapy. What is the nurse's priority action in monitoring the client's response to the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a client at risk of deep vein thrombosis (DVT). What is the most crucial instruction the nurse should include in the client's teaching plan?

Correct Answer is A

Explanation

A client is prescribed estrogen-based hormone replacement therapy. What risk factor for deep vein thrombosis (DVT) should the nurse identify in this client?

Correct Answer is D

Explanation

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