A nurse is planning care for a client who has a deep vein thrombosis in the right leg. Which is the following actions should the nurse include in the plan?

Maintain client on bed rest

Elevate the client's affected extremity.

Apply cold compresses to the client's affected extremity

Massage the muscle of the client's affected extremity

Answer and Explanation

The Correct Answer is B

A. Maintain client on bed rest: Strict bed rest is no longer routinely recommended for DVT unless complications arise. Early ambulation, if not contraindicated, can help prevent further clot formation and promote circulation. Prolonged immobilization may increase the risk of thrombus extension.

B. Elevate the client's affected extremity: Elevating the affected leg above heart level helps reduce venous pressure, swelling, and discomfort associated with DVT. This non-invasive intervention promotes venous return without increasing the risk of dislodging the thrombus, making it a safe and effective component of care.

C. Apply cold compresses to the client's affected extremity: Cold compresses are typically used for acute inflammation or localized trauma. In DVT, applying cold may not provide significant benefit and does not address the underlying venous obstruction or edema, so it is not routinely recommended.

D. Massage the muscle of the client's affected extremity: Massaging a limb with DVT is contraindicated because it can dislodge the thrombus, potentially causing a life-threatening pulmonary embolism. This action poses a high safety risk and must be strictly avoided.

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Correct Answer is C

Explanation

A. Decrease intake of citrus foods and beverages: Citrus foods and beverages do not increase the risk of UTIs and may actually support general health through vitamin C. Restricting them is unnecessary and not part of standard UTI prevention education.

B. Wear nylon underwear: Nylon underwear is less breathable than cotton and can increase moisture, promoting bacterial growth. Clients should be advised to wear cotton underwear to reduce UTI risk.

C. Empty the bladder before and after intercourse: Urinating before and after sexual activity helps flush bacteria from the urethra, reducing the risk of infection. This is an effective and recommended preventive measure for clients with a history of UTIs.

D. Increase the time between voiding: Holding urine for extended periods allows bacteria to multiply in the urinary tract and increases the risk of infection. Clients should be advised to void regularly to prevent UTIs.

A. A client who has a productive cough and an oral temperature of 36° C (96.8°F). B. A client who reports tingling in the fingers following a thyroidectomy. C. A client who is in a long leg cast and has +2 pedal pulses bilaterally. D. A client who has dark, foul-smelling urine and a urine output of 320 mL in the last 8 hr

Correct Answer is B

Explanation

A. A client who has a productive cough and an oral temperature of 36° C (96.8°F): A normal temperature and stable vital signs indicate that this client’s condition is not immediately life-threatening. Assessment is important but not the priority.

B. A client who reports tingling in the fingers following a thyroidectomy: Tingling in the fingers may indicate hypocalcemia from potential injury or removal of the parathyroid glands during thyroidectomy. This is an acute complication that can lead to tetany or cardiac dysrhythmias, making it the highest priority.

C. A client who is in a long leg cast and has +2 pedal pulses bilaterally: Adequate pedal pulses indicate good circulation. While monitoring for neurovascular compromise is necessary, this client is currently stable.

D. A client who has dark, foul-smelling urine and a urine output of 320 mL in the last 8 hr: Oliguria and infection risk are concerning and require follow-up, but these findings do not pose an immediate threat compared with potential hypocalcemia after thyroid surgery.

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A nurse is planning care for a client who has a deep vein thrombosis in the right leg. Which is the following actions should the nurse include in the plan?

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