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 B

Explanation

A. S3 heart sound: An S3 heart sound is often associated with heart failure and volume overload, not specifically mitral stenosis.

B. Dyspnea on exertion: Dyspnea on exertion is a classic symptom of mitral stenosis. The narrowing of the mitral valve restricts blood flow from the left atrium to the left ventricle, causing pulmonary congestion and shortness of breath, especially during physical activity.

C. Cyanosis: While cyanosis can occur in advanced stages of heart disease, it is not a primary symptom of mitral stenosis. It indicates severe oxygenation issues, which are usually late findings.

D. S4 heart sound: An S4 heart sound is typically associated with left ventricular hypertrophy, which can occur in advanced cases of mitral stenosis. However, it's not a specific early manifestation of the condition.

A. Emboli B. A heart murmur C. Petechiae D. Fever

Correct Answer is A

Explanation

A. Emboli: Emboli can form as vegetations break off from the heart valves and travel to other parts of the body, causing complications such as stroke, pulmonary embolism, or organ infarction.

B. A heart murmur: A heart murmur is a common symptom of infective endocarditis but not a complication. It results from valve damage caused by the infection.

C. Petechiae: Petechiae are a manifestation of infective endocarditis, not a complication. They occur due to the damage to blood vessels by emboli or infection.

D. Fever: Fever is a common sign of infective endocarditis due to the ongoing infection but is not considered a complication.

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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

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