A nurse is assisting with the care of a client who is admitted to the medical surgical unit.

Complete the following sentences by using the list of options:

The nurse anticipates the client will likely require

______

as evidenced by the client’s

_______

and

______

.

A) Administer aspirin for pain: Aspirin is an anticoagulant and should be avoided in clients receiving other anticoagulant therapy, especially in the context of deep vein thrombosis (DVT). Using aspirin could increase the risk of bleeding and complications. Therefore, it is not appropriate for pain management in this situation.

B) Initiate bed rest: While rest may be indicated for comfort and to reduce the risk of further clot formation, complete bed rest is generally not recommended in the management of DVT unless specifically directed by the healthcare provider. Early ambulation and the use of compression devices or stockings are typically encouraged to promote circulation and reduce the risk of complications, such as pulmonary embolism.

C) Massage the affected extremity every 4 hr: Massaging the affected extremity is contraindicated in a client with DVT, as it can dislodge the clot and increase the risk of a pulmonary embolism or other complications. It is important to avoid any direct manipulation of the affected limb to prevent causing harm.

D) Apply an ice pack to the affected extremity for 20 min every 2 hr: Applying an ice pack is
an appropriate intervention for reducing swelling and providing comfort in the case of a DVT. The cold therapy helps to constrict blood vessels, reduce inflammation, and relieve pain. This intervention should be done carefully to avoid skin damage, and the nurse should monitor the skin for signs of injury.

A) "Draw up the insulin lispro and insulin glargine in separate syringes.":
Insulin lispro (a rapid-acting insulin) and insulin glargine (a long-acting insulin) should be administered separately, as they have different properties and mechanisms of action. Mixing them in one syringe can affect their effectiveness and may cause inaccurate dosing. Therefore, the nurse should instruct the client to draw up each insulin in a separate syringe to ensure proper administration and action of both insulins.

B) "Take an extra dose of insulin lispro prior to aerobic exercise.":
Taking an extra dose of insulin lispro before exercise is not recommended unless directed by a healthcare provider. Exercise can lower blood glucose levels, and additional insulin may increase the risk of hypoglycemia. Instead, clients with diabetes are typically advised to monitor their blood glucose levels before and after exercise and adjust their insulin dose or carbohydrate intake accordingly, under the guidance of their healthcare provider.

C) "Expect insulin glargine to be cloudy.":
Insulin glargine is a clear, long-acting insulin. It should not be cloudy. If the insulin appears cloudy, it may be a sign that the insulin has been improperly stored or is no longer effective. The nurse should educate the client to inspect the insulin for cloudiness or particles and to discard any insulin that appears abnormal.

D) "Anticipate that the insulin glargine will peak in 3 hours.":
Insulin glargine is a long-acting insulin that does not have a pronounced peak. It provides a steady release of insulin over 24 hours and helps to maintain baseline insulin levels. It is not meant to peak like rapid-acting or short-acting insulins. Therefore, this instruction is incorrect, as insulin glargine does not follow the same peak-action pattern as other insulins.