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 B

Explanation

Correct answer: B

A.Family presence can provide comfort and support to the toddler, making mealtimes a more positive experience. It can also encourage the child to eat more by setting a good example. However, without first understanding the child's dietary habits and possible issues, this intervention might not address the root cause of the poor intake.

B.The nurse’sfirst actionin caring for a toddler with poor dietary intake should be toobtain the child’s dietary history. Understanding the child’s current eating habits, preferences, and any potential barriers to adequate nutrition is essential for planning appropriate interventions. Once the dietary history is obtained, the nurse can tailor further actions based on the specific needs of the child.

C.Offering nutritious snacks can help increase the child's overall calorie and nutrient intake, which is particularly important if the child has a low appetite during regular meals. Nevertheless, this step should follow the assessment of the child's dietary history to ensure that the snacks offered are appropriate and to avoid potential allergies or intolerances.

D.Positive reinforcement can encourage healthy eating behaviors and make mealtime a more enjoyable experience for the child. Praising the child can motivate them to eat more. However, this should be done after understanding the child's eating patterns and preferences to ensure that the praise is given in a context that promotes effective and lasting change.

A. Apply suction while inserting the catheter. B. Apply intermittent suction for 15 seconds. C. Wait 1 min between suctioning attempts. D. Insert the catheter 10 cm (4 in).

Correct Answer is C

Explanation

A.This is incorrect because suction should not be applied during the insertion of the catheter. Suctioning should only be applied while withdrawing the catheter to avoid causing trauma to the mucosa.

B. Suctioning should generally be performed for no longer than 10 seconds at a time to minimize the risk of complications such as hypoxia.

C.This response is correct because waiting approximately 1 minute between suctioning attempts allows the client time to recover and reoxygenate. This interval helps prevent hypoxia and mucosal damage, which are important considerations during the suctioning process.

D.In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.

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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?

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