A nurse is assuming care of a client who has an existing deep-vein thrombosis (DVT). What interventions would be anticipated in their plan of care? (Select All that Apply).
Encourage and assist with turning every 2 hours.
Position the legs dependently.
Administer ibuprofen for pain relief.
Monitor platelet levels.
Apply ice to the extremity.
Evaluate fit of compression stockings.
Correct Answer : A,D,F
Choice A rationale
Encouraging and assisting with turning every 2 hours is a standard intervention for any client with restricted mobility, including those on bedrest due to DVT. This measure helps prevent skin breakdown and pressure ulcers by relieving pressure over bony prominences and promoting circulation to compressed tissues.
Choice B rationale
Positioning the legs dependently (hanging down) would increase venous pressure and worsen venous pooling and edema distal to the DVT site due to the effects of gravity, which could potentially increase pain and swelling. The affected leg should be elevated above the level of the heart to promote venous return and reduce edema and pressure.
Choice C rationale
Ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), inhibits platelet aggregation and may increase the risk of bleeding when used concurrently with therapeutic anticoagulants like heparin or warfarin, which are standard DVT treatments. Acetaminophen (Tylenol) is generally preferred for pain management due to its lower bleeding risk.
Choice D rationale
Heparin (unfractionated or low molecular weight) is a common treatment for DVT. A severe complication of heparin therapy is Heparin-Induced Thrombocytopenia (HIT), an immune reaction leading to a significant drop in platelet count (normal range 150,000–450,000/mm) and paradoxical thrombosis. Therefore, monitoring platelet levels is crucial.
Choice E rationale
Applying ice (cold) to the extremity is a vasoconstrictor that can impair circulation and may reduce pain but is not the primary intervention for an acute DVT; it could theoretically worsen flow. Moist heat application is often preferred to promote vasodilation, which may reduce muscle spasms and provide comfort.
Choice F rationale
Compression stockings (graduated compression) help to reduce edema and promote venous return from the lower extremities, thereby reducing the symptoms of Post-Thrombotic Syndrome (PTS). The nurse must evaluate the fit to ensure the stockings are not too tight (risk for impaired arterial circulation) or too loose (ineffective compression).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Compression is a key component of the R.I.C.E. (Rest, Ice, Compression, Elevation) protocol, which is the standard treatment for acute sprains. Applying an elastic bandage or wrap to the injured ankle reduces interstitial edema and internal bleeding by increasing external tissue pressure, thereby limiting the development of excessive swelling and contributing to pain reduction and faster healing.
Choice B rationale
Elevation of the injured ankle above the level of the heart utilizes gravity to decrease hydrostatic pressure in the local capillaries. This physiological mechanism promotes the venous and lymphatic return of excess interstitial fluid and accumulated inflammatory exudate from the injured area back into central circulation, which significantly minimizes swelling and throbbing pain.
Choice C rationale
Applying heat to an acute injury, such as an ankle sprain, is contraindicated within the first 48 to 72 hours. Heat induces vasodilation, which would increase blood flow and capillary permeability to the site, thus exacerbating the acute inflammatory response, edema, and localized hemorrhage, leading to significantly increased swelling, pain, and potentially delayed healing.
Choice D rationale
Movement (especially weight-bearing or full range of motion) is generally discouraged in the acute phase of an ankle sprain. Early movement can disrupt the initial healing of the damaged ligaments and potentially cause further microtrauma, increasing inflammation, pain, and instability. Immobilization and protected range of motion are preferred to allow the initial repair processes to establish stability.
Choice E rationale
Rest is essential to minimize mechanical stress on the injured ligaments and soft tissues, which allows the initial inflammatory and repair phases of healing to occur unimpeded. Resting the joint prevents the further tearing of damaged fibers and the aggravation of surrounding tissues, reducing pain signals and minimizing metabolic demand, thereby facilitating the body's natural regenerative processes.
Correct Answer is A
Explanation
Choice A rationale
Applying a constrictive bandage wrap to a bleeding site in a client receiving enoxaparin sodium, a low molecular weight heparin that inhibits factor Xa and thrombin generation, may cause a tourniquet effect; this can impede distal blood flow and potentially increase the risk of compartment syndrome, especially with internal bleeding. Direct pressure is preferred initially.
Choice B rationale
Monitoring the site for re-bleeding is crucial because enoxaparin extends clotting time, necessitating vigilant observation for recurrent hemorrhage after initial control. The standard Activated Partial Thromboplastin Time (aPTT) range is typically 30-40 seconds, and enoxaparin significantly prolongs this, increasing bleeding risk; early detection is essential for intervention.
Choice C rationale
Elevating the affected area utilizes gravity to decrease hydrostatic pressure in the capillaries and venules of the injured extremity, subsequently promoting venous return and reducing arterial inflow pressure. This physiological mechanism helps to slow the rate of blood loss and reduce local tissue swelling following an injury.
Choice D rationale
Resting to minimize the risk of re-bleeding reduces physical activity and muscular contractions, which can increase local blood flow and dislodge a forming clot. Reduced movement is vital because enoxaparin impairs the intrinsic clotting cascade, making clot stabilization and maintenance dependent on low pressure and minimal mechanical stress.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.