A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?
Massage the affected extremity every 4 hr.
Initiate bed rest.
Apply an ice pack to the effected extremity for 20 min every 2 hr.
Administer aspirin for pain.
The Correct Answer is B
Deep-vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the legs. Bed rest is often recommended for clients with DVT to reduce the risk of the clot dislodging and causing a pulmonary embolism. By minimizing movement and keeping the leg elevated, the nurse can help prevent further complications.
The other options listed are incorrect:
- Massage the affected extremity every 4 hours: Massaging the affected extremity can dislodge the clot, increasing the risk of a pulmonary embolism. It is contraindicated and should not be performed in clients with DVT.
- Apply an ice pack to the affected extremity for 20 minutes every 2 hours: While applying cold compresses or ice packs may be useful in some situations to reduce swelling or pain, it is not recommended for clients with DVT. Heat application or cold application should be avoided because they can promote blood circulation and potentially dislodge the clot.
- Administer aspirin for pain: Aspirin is not typically used for pain management in DVT. Anticoagulant therapy is the primary treatment for DVT, and specific anticoagulant medications are prescribed to prevent further clot formation and reduce the risk of complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Among the given options, 240 mL (8 oz) of hot cocoa typically contains the least amount of caffeine. While the exact caffeine content can vary depending on the brand and preparation method, hot cocoa is generally considered to have a lower caffeine content compared to brewed green tea, instant coffee, or cola soft drinks.
However, it's worth noting that hot cocoa may still contain a small amount of caffeine, although significantly less than the other options mentioned.
Correct Answer is A
Explanation
Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.
Incorrect:
B- Limit documentation to subjective information: This is an incorrect action to take.
Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.
C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.
D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.
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