A nurse is evaluating a client who is at risk for deep-vein thrombosis (DVT). Which of the following symptoms is an indication of DVT?

Choice A rationale
Maintaining systolic BP between 136 and 140 mm Hg is not recommended for clients who have hypertension and have experienced a TIA789. Studies have shown that maintaining a lower systolic BP can help reduce the risk of recurrent stroke.
Choice B rationale
The client should aim to maintain systolic BP between 120 and 129 mm Hg. This range is associated with a reduced risk of recurrent stroke. Lifestyle modifications and antihypertensive therapy can help achieve this target.
Choice C rationale

Maintaining systolic BP between 141 and 145 mm Hg is not recommended for clients who have hypertension and have experienced a TIA789. This range is higher than the recommended target and may increase the risk of recurrent stroke.
Choice D rationale
Maintaining systolic BP between 130 and 135 mm Hg is not the recommended target for clients who have hypertension and have experienced a TIA789. The recommended target is lower to help reduce the risk of recurrent stroke.

Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale

Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.