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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Chadwick’s sign

Chadwick's sign is a characteristic change that occurs during pregnancy, specifically in the cervix, vagina, and vulva. It is characterized by a bluish or purplish discoloration of these areas.

Chloasma in (option B) is incorrect because it is a condition characterized by the development of dark patches on the skin, commonly referred to as "mask of pregnancy." Chloasma typically affects the face, particularly the cheeks, forehead, and upper lip. It is not associated with a change in colour in the vaginal or vulvar area.

Hegar's sign in (option C) is incorrect because it is a softening of the lower uterine segment that can be felt during a pelvic examination. It is not related to the colour changes in the vaginal or vulvar area.

Ballottement in (option D) is incorrect because it is a palpation technique used during a prenatal examination to assess the position of the foetus. It involves the examiner gently pushing against the uterus and feeling a rebound or "floating" movement of the foetus. It does not involve changes in the colour of the vaginal or vulvar area.

A. Soiled linens are placed on the floor B. Waste containers are lined with single bags C. Dampened cloths are used for dusting the area D. Uncapped sharps are put in a puncture-resistant container

Correct Answer is A

Explanation

Placing soiled linens on the floor can lead to cross-contamination and the spread of infectious agents. This can pose a risk to the immunocompromised client, who may be more susceptible to infections.

Lining waste containers with single bags helps contain potentially infectious waste and facilitates proper disposal. This reduces the risk of contamination and exposure to infectious materials.

Using dampened cloths for dusting helps minimize the spread of dust and airborne particles. Dampening the cloth can help capture the dust and prevent it from becoming airborne, reducing the potential for respiratory exposure.

Placing uncapped sharps in a puncture-resistant container is an essential practice to prevent needlestick injuries and the transmission of bloodborne pathogens. This ensures safe disposal of sharps and reduces the risk of accidental needlestick injuries to healthcare workers and clients.

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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?

Nursing Test Bank

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