A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take?

Apply a cold compress to the affected extremity.

Teach the client to massage the affected extremity.

Instruct the client to elevate the affected extremity when sitting.

Assess pulses proximal to the affected area.

Answer and Explanation

The Correct Answer is C

A. Applying a cold compress is not recommended for DVT; instead, heat may be more appropriate to alleviate discomfort and improve circulation.

B. Massaging the affected extremity is contraindicated as it can dislodge the clot and lead to complications such as pulmonary embolism.

C. Instructing the client to elevate the affected extremity helps reduce swelling and promote venous return, making it the best action.

D. Assessing pulses proximal to the affected area is important for monitoring circulation, but it is not the primary intervention for managing DVT.

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Correct Answer is A

Explanation

A. Having the client wear a surgical mask while being transported outside the room is essential to prevent the transmission of TB to others. This minimizes exposure to airborne droplets.

B. Wearing a surgical mask while providing care for the client is not sufficient for preventing TB transmission; an N95 respirator is required to protect healthcare workers from inhaling airborne particles.

C. While restricting visitors may help limit exposure, it is not the most effective preventive measure compared to ensuring that the client wears a mask when out of their room.

D. Initiating contact precautions is not necessary for TB, as it primarily requires airborne precautions. Airborne isolation precautions should be followed, including the use of N95 respirators for healthcare workers and appropriate ventilation.

A. Dietary salt restriction B. Absence of symptoms C. Addition of a new medication D. A detailed plan of care

Correct Answer is B

Explanation

A. Dietary salt restriction can be challenging, but patients often adapt over time with education and support; it is not usually the greatest barrier.

B. Many clients with high blood pressure feel well despite elevated readings, so the absence of symptoms can lead them to underestimate the seriousness of their condition and skip medications, making this the most significant barrier.

C. Adding a new medication may complicate the regimen, but understanding its purpose can improve adherence; it is less influential than asymptomatic disease.

D. A detailed plan of care is intended to guide the client, and while complexity can be a barrier, it is typically easier to address with education and support than the lack of perceived need due to no symptoms.

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A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take?

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