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 A

Explanation

Choice A reason : Hepatomegaly, or the enlargement of the liver, is a common finding in right-sided heart failure. This condition occurs because the heart does not pump blood effectively, leading to congestion and increased pressure in the venous system, including the hepatic veins. As a result, the liver becomes engorged with blood, causing it to enlarge. The normal liver span in adults is about 10-12 cm in the midclavicular line, and any measurement above this can indicate hepatomegaly.

Choice B reason : Orthopnea, which is shortness of breath while lying flat, is more commonly associated with left-sided heart failure. In right-sided heart failure, symptoms are more related to systemic congestion, such as swelling in the legs and abdomen, rather than pulmonary symptoms like orthopnea.

Choice C reason : Dyspnea, or difficulty breathing, can be a symptom of both left and right-sided heart failure. However, in the context of right-sided heart failure, dyspnea is usually due to the accumulation of fluid in the abdominal cavity (ascites) and the increased pressure in the abdominal veins, which can compress the diaphragm and make breathing difficult.

Choice D reason : Frothy sputum is typically not a symptom of right-sided heart failure. It is more indicative of pulmonary edema, which is associated with left-sided heart failure. In right-sided heart failure, the primary issues are related to the systemic circulation and venous congestion.

A. Probiotics B. Garlic C. Ginger root D. Valerian

Correct Answer is B

Explanation

Choice A reason : Probiotics are beneficial for gut health and may have a role in maintaining a healthy immune system, but they are not primarily known for lowering blood pressure. While some studies suggest a potential benefit of probiotics on blood pressure, more research is needed to establish a direct effect.

Choice B reason : Garlic is well-known for its potential benefits in lowering blood pressure. It contains allicin, which is thought to help relax blood vessels and improve blood flow, thereby reducing blood pressure. Studies have shown that garlic supplements can have a significant impact on reducing blood pressure in individuals with hypertension.

Choice C reason : Ginger root is commonly used for its anti-inflammatory properties and gastrointestinal benefits. Some studies suggest that ginger may help lower blood pressure, but the evidence is not as strong as it is for garlic. Therefore, it is not the primary recommendation for hypertension management.

Choice D reason : Valerian is often used for its sedative effects and to aid sleep. There is limited evidence to suggest that valerian has any significant impact on blood pressure. It is not typically recommended as a treatment for hypertension.

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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?

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