A nurse is contributing to the care plan of a client who is postoperative and has an increased risk for deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan? (Select all that apply)

Assist with ordered exercise as needed

Encourage fluids

measure affected limb circumference

massage calves and thighs

Apply compression stockings

Answer and Explanation

Correct Answer : A,B,C,E

A. Assist with ordered exercise as needed: Mobility and exercises such as ankle pumps help promote circulation and prevent venous stasis, reducing the risk of DVT.

B. Encourage fluids: Encouraging fluids helps prevent dehydration, which reduces blood viscosity and lowers the risk of clot formation.

C. Measure affected limb circumference: Measuring limb circumference is important for detecting early signs of DVT, such as swelling in the affected limb.

D. Massage calves and thighs: Massaging the legs is contraindicated in clients at risk for DVT as it can dislodge a clot, leading to a pulmonary embolism.

E. Apply compression stockings: Compression stockings promote venous return and reduce the risk of blood pooling in the lower extremities, thus preventing DVT.

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Correct Answer is C

Explanation

A. The QT interval is equal to the R to R interval. This is not a finding associated with myocardial infarction. QT interval changes are more related to electrolyte imbalances or medication effects.

B. The QRS intervals are 0.08 second. A QRS duration of 0.08 seconds is normal and does not indicate myocardial infarction. Prolongation of the QRS complex might suggest a bundle branch block or other conduction issues.

C. The ST segment is above the isoelectric line. ST-segment elevation is a hallmark sign of an acute myocardial infarction (STEMI). It reflects injury to the heart muscle.

D. The PR intervals are 0.15 second. A PR interval of 0.15 seconds is within the normal range (0.12–0.20 seconds) and does not indicate myocardial infarction.

A. Soft, pliable calf muscle B. Cool and clammy skin C. Dull, aching calf pain D. Temperature > 100 F

Correct Answer is C

Explanation

A. Soft, pliable calf muscle: A soft and pliable calf muscle is not indicative of a thrombus. Typically, a thrombus leads to swelling and firmness in the affected area.

B. Cool and clammy skin: Cool and clammy skin could indicate poor circulation, but it is not specific to a thrombus.

C. Dull, aching calf pain: Dull, aching calf pain is a key symptom of deep vein thrombosis (DVT) and should prompt further investigation.

D. Temperature > 100°F: A fever could indicate an infection but is not a classic sign of a thrombus.

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A nurse is contributing to the care plan of a client who is postoperative and has an increased risk for deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is C

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