A nurse is contributing to the plan of care for a client who is admitted with deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

Apply ice to the extremity.

Administer vasodilating medications.

Restrict oral fluids.

Monitor platelet levels.

Answer and Explanation

The Correct Answer is D

Choice A reason : Applying ice to the extremity is not a standard intervention for DVT. Ice is typically used to reduce inflammation and pain, but in the case of DVT, the priority is to prevent the clot from growing and embolizing. The use of warmth, not cold, may be recommended to help reduce discomfort and swelling.

Choice B reason : Administering vasodilating medications is not a typical intervention for DVT. Vasodilators are used to widen blood vessels and improve blood flow, but they do not address the risk of clot formation or embolization associated with DVT. The mainstay of medical treatment for DVT is anticoagulant therapy, which helps to prevent further clotting.

Choice C reason : Restricting oral fluids is not an intervention for DVT. Adequate hydration is important in the management of DVT as it can help to prevent blood from thickening and reduce the risk of further clot formation. There is no indication to restrict fluids unless there is another underlying condition that requires it.

Choice D reason : Monitoring platelet levels is an important intervention in the care of a client with DVT, especially if they are receiving anticoagulant therapy. Anticoagulants can affect platelet function and count, and monitoring is necessary to ensure safe levels and prevent complications such as bleeding or thrombocytopenia.

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Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Monitoring cholesterol levels is essential while taking lisinopril. This medication is an angiotensin-converting enzyme (ACE) inhibitor used to treat high blood pressure, heart failure, and heart attack. Regular monitoring helps assess the impact of lisinopril on lipid levels and overall cardiovascular health. Elevated cholesterol can contribute to heart disease, so monitoring allows for timely interventions and adjustments in treatment.

Choice C reason: Potassium-rich foods are relevant because lisinopril can affect potassium levels. ACE inhibitors may lead to hyperkalemia (high potassium levels), especially in patients with impaired kidney function. Encouraging potassium-rich foods helps maintain a balance and prevent complications.

Choice D reason: Reporting a persistent dry cough is crucial. Lisinopril is associated with a common side effect: a dry, persistent cough. This occurs due to increased levels of bradykinin, a substance affected by ACE inhibitors. If the client experiences this cough, it's essential to notify the doctor for potential medication adjustments.

Choice E reason: Monitoring blood pressure aligns with the purpose of lisinopril. Regular blood pressure checks help assess the effectiveness of the medication in controlling hypertension. Consistent monitoring ensures timely adjustments and prevents complications related to high blood pressure.

A. Set your goal body weight within 25% of your ideal body weight. B. Limit alcohol consumption to two drinks a day for men and one drink a day for women when hypertensive. C. Plan to lower sodium intake to less than 2,300 mg each day. D. Plan to have potassium blood levels checked when taking thiazide diuretics. E. None F. None

Correct Answer is C

Explanation

Choice A reason : Setting a goal body weight within 25% of the ideal body weight can be misleading. The ideal body weight should be determined based on body mass index (BMI), considering the individual's height and weight. A BMI of 18.5 to 24.9 is considered normal.

Choice B reason : This is a general guideline for alcohol consumption, but for individuals with hypertension, it is often recommended to limit alcohol intake even further to help manage blood pressure

Choice C reason : This is a key recommendation for managing hypertension. Reducing sodium intake helps lower blood pressure and is a widely accepted guideline

Choice D reason : Monitoring potassium levels is crucial when taking thiazide diuretics because these medications can decrease potassium levels in the blood, leading to hypokalemia.

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A nurse is contributing to the plan of care for a client who is admitted with deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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