A nurse is collecting data from a client who is postoperative and has a deep vein thrombosis of the right calf. Which of the following actions should the nurse take?
Apply cool compresses to the right calf.
Place the right leg in a dependent position.
Maintain the client on bed rest.
Decrease the client's fluid intake.
The Correct Answer is C
Choice A reason: Applying cool compresses may provide some relief but is not the primary action to be taken for DVT.
Choice B reason: Placing the leg in a dependent position can increase swelling and pain and is not recommended for DVT.
Choice C reason: Maintaining the client on bed rest is important to prevent the clot from dislodging and causing a pulmonary embolism.
Choice D reason: Decreasing fluid intake is not recommended as adequate hydration can help prevent further clot formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Suctioning for less than 15 seconds is recommended to minimize the risk of hypoxia and other complications during tracheal suctioning.
Choice B reason: Setting the suction pressure dial between 80 and 120 may be too high and could cause trauma to the tracheal mucosa.
Choice C reason: Wrapping used suction catheters in a clean towel for later use is not recommended due to the risk of infection.
Choice D reason: Suctioning the mouth before the tracheostomy can introduce oral bacteria into the lower airways and should be avoided.
Correct Answer is B
Explanation
Choice A reason: Sterile gloves should be donned after removing the old dressing and before handling the new sterile dressing.
Choice B reason: Offering pain medication before the procedure can help manage discomfort during the dressing change.
Choice C reason: Disinfecting the wound bed with alcohol is not recommended as it can damage new tissue and delay healing.
Choice D reason: Preparing sterile dressing supplies should be done just before the dressing change to maintain sterility.
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