A nurse is performing an electrocardiogram (ECG) on a client who is experiencing chest pain. Which of the following statements should the nurse make?

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.

Choice A reason : Dyspnea, or difficulty breathing, is a common symptom of left-sided heart failure. It occurs because the heart is unable to pump efficiently, leading to a backup of fluid in the lungs, which can cause shortness of breath.

Choice B reason : Jugular vein distention is typically associated with right-sided heart failure, not left-sided. It occurs when there is an increased pressure in the right atrium, leading to visible bulging of the neck veins.

Choice C reason : Orthopnea, or difficulty breathing while lying flat, is another symptom of left-sided heart failure. Fluid accumulation in the lungs makes it difficult for the patient to breathe without elevation, hence they may need to sleep with extra pillows.

Choice D reason : Crackles, which are heard during lung auscultation, are indicative of fluid accumulation in the alveoli due to the inefficiency of the left side of the heart to pump blood, leading to pulmonary congestion.

Choice E reason : Tachycardia, or rapid heartbeat, can be a response to left-sided heart failure as the body attempts to compensate for the decreased cardiac output by increasing the heart rate to maintain adequate blood flow.

Choice F reason : Gastrointestinal bloating is more commonly associated with right-sided heart failure due to systemic venous congestion leading to fluid accumulation in the abdominal organs and tissues.