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.
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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Related Questions
Correct Answer is C
Explanation
A. The reason for the medication error should not be documented in the client's medical record due to potential legal implications; such information belongs in the incident report instead.
B. Documentation of notification to the pharmacist is relevant for the incident report but is not appropriate for the client's medical record.
C. The time the medication was given is an important detail that should be documented in the client's medical record as it affects the client's treatment and future medication administration.
D. Documenting the completion of the incident report should be done in the facility's quality assurance system, not in the client’s medical record.
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.
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