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. Obtain platelet aggregation studies to confirm DVT. Platelet aggregation studies are not used to diagnose deep vein thrombosis (DVT). They are more relevant for evaluating platelet function and clotting disorders.

B. Schedule deep tissue massage with physical therapy. Deep tissue massage is contraindicated in clients suspected of having DVT, as it could dislodge the clot and cause a pulmonary embolism or other complications.

C. Arrange for a venous duplex ultrasound. A venous duplex ultrasound is the standard diagnostic test used to confirm DVT. It visualizes the veins and assesses blood flow, helping to detect the presence of a clot.

D. Monitor Homan's sign. Homan’s sign (pain in the calf with dorsiflexion of the foot) was once considered a diagnostic indicator of DVT, but it is no longer considered reliable due to its low sensitivity and specificity. Therefore, it is not routinely used for DVT diagnosis.

A. Keep the affected knee flexed. B. Encourage increased fluid intake. C. Massage the client's calf on the affected side. D. Promote bed rest for 5-10 days.

Correct Answer is B

Explanation

A. Keep the affected knee flexed. Flexing the knee for prolonged periods can impede venous return and increase the risk of thrombosis. The knee should be extended, not flexed.

B. Encourage increased fluid intake. Encouraging fluid intake helps to prevent dehydration, which is a risk factor for blood clot formation. Adequate hydration helps keep the blood less viscous and reduces the risk of DVT.

C. Massage the client's calf on the affected side. Massaging the calf could dislodge a clot if one is present, leading to serious complications such as a pulmonary embolism. This is contraindicated.

D. Promote bed rest for 5-10 days. Early ambulation and movement are key to preventing DVT after surgery. Prolonged bed rest increases the risk of DVT due to venous stasis.

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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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