A nurse is caring for a client who has prescriptions for furosemide and gentamicin. For which of the following complications should the nurse monitor the client?

Rationale:

A. Provide the child with electronics to watch movies: While distraction can be helpful in managing anxiety or discomfort, it does not directly address the child’s feelings about hair loss. Emotional support specific to the child’s concern is more appropriate in this situation.

B. Tell the child there's no need to cry because this is expected: Minimizing the child’s feelings invalidates their emotional experience and can increase distress. Acknowledging and supporting the child’s emotions is essential for coping during hair loss caused by radiation therapy.

C. Provide the child with a doll that does not have any hair: Giving a doll without hair helps the child normalize hair loss and provides a concrete way to express and cope with feelings. This action demonstrates understanding, empathy, and age-appropriate support for the child’s emotional needs.

D. Tell the child not to worry about their hair loss because their hair will grow back: While it is true that hair often regrows after treatment, reassurance alone does not address the child’s immediate emotional reaction. Supporting the child’s feelings and providing relatable coping strategies is more effective.

Rationale for correct choices

• heparin 30 units/kg IV bolus once: The diagnostic ultrasound confirms a thrombus in the right leg, indicating acute DVT. Anticoagulation with heparin is the first-line intervention to prevent clot extension and pulmonary embolism. The lab values (normal platelets, normal INR) show no contraindication to starting anticoagulation.

• acetaminophen 650 mg PO every 4 hr PRN: Acetaminophen is appropriate for managing the client’s pain (rated 6/10) without increasing bleeding risk. NSAIDs such as ibuprofen are avoided in DVT because they can impair platelet function and increase bleeding risk once anticoagulation is initiated.

Rationale for incorrect choices

• initiating fluid restriction: Fluid restriction is typically used in conditions like heart failure or hyponatremia, not DVT. Adequate hydration is beneficial in DVT because it helps maintain blood viscosity and supports circulation without affecting clot stability.

• maintaining the extremity below the level of the heart: Lowering the extremity increases venous pressure and can worsen swelling. For DVT, the extremity is usually elevated to promote venous return and reduce edema, so this option does not align with recommended care.

• administering cold packs to the extremity: Cold therapy can cause vasoconstriction and slow venous blood flow, which may worsen thrombosis. Warm compresses improve circulation but are used cautiously and only with provider guidance.