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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation
A. Increased erythrocyte sedimentation rate
A. Increased erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation in the body. In the presence of an infection, the ESR tends to rise due to increased levels of acute-phase reactants, such as fibrinogen and globulins. However, it is important to note that an increased ESR alone does not diagnose a specific infection but rather indicates the presence of inflammation or infection.
Decreased platelets in (option B) should not be included because they are not typically associated with infection. Low platelet levels (thrombocytopenia) may occur due to various reasons, such as certain medications, immune disorders, or bone marrow problems, but they are not directly linked to infections.
Increased iron level in (option C) should not be included because it is not a typical finding in an active infection. In fact, during an infection, iron levels tend to decrease in response to the body's efforts to withhold iron from pathogens, as most microorganisms require iron for their growth and survival.
Decreased haemoglobin in (option D) should not be included because it is not directly indicative of an infection. A decrease in hemoglobin levels may be associated with conditions such as anaemia, blood loss, or certain chronic diseases, but it is not a specific marker for infection.
Correct Answer is B
Explanation
Disorientation is a common side effect of ECT and is typically temporary. It may include confusion and difficulty recalling recent events or personal information. This post-treatment disorientation is often referred to as the "postictal state" and usually resolves within a short period of time.
Sleep apnea, tonic-clonic seizures, and paresthesias are not expected findings following ECT and would require immediate attention and intervention if they were to occur. It is important for the nurse to closely monitor the client's vital signs, oxygen saturation levels, and neurological status after the procedure to ensure their safety and well-being.
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