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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Related Questions
Correct Answer is ["A","B","C","E","G"]
Explanation
Based on the given information, the nurse should take the following actions in preparation for surgery:
- Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
- Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
- Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to Rh-positive blood.
- Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
- Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.
The following actions are not indicated based on the given information:
- Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
- Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.
Correct Answer is C
Explanation
This statement reflects appropriate newborn care as newborns have sensitive skin, and using soap on the face can cause irritation. Washing the baby's face with a warm, wet washcloth is a gentle and effective way to clean the baby's face without the need for soap.
Moist towelettes may not be suitable for cleaning a newborn's head as they may contain chemicals or fragrances that can be harsh on the baby's delicate skin. It is generally recommended to use a soft, damp cloth for cleaning the baby's head.
Bathing a newborn under a faucet of running water can be unsafe as the water temperature may fluctuate and pose a risk of scalding. It is recommended to use a baby bathtub or a basin with warm water for bathing the baby.
Newborns do not need to be bathed daily as frequent bathing can strip their skin of natural oils and cause dryness. It is generally recommended to bathe newborns 2-3 times a week or as needed, focusing on areas that need cleaning such as the diaper area and skin folds.
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