A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?
Apply ice packs to affected leg.
Keep the client's affected leg elevated while in bed.
Have the client ambulate prior to applying antiembolic stockings.
Massage the client's affected leg twice a day.
The Correct Answer is B
A. Apply ice packs to affected leg: While ice can help reduce swelling and pain in some conditions, it is not typically recommended for deep vein thrombosis (DVT) because it could increase the risk of clot dislodgement.
B. Keep the client's affected leg elevated while in bed: Elevating the leg helps reduce swelling and promotes venous return, which is important in managing DVT.
C. Have the client ambulate prior to applying antiembolic stockings: Ambulation is usually avoided initially in the presence of DVT until anticoagulation therapy is started to reduce the risk of clot dislodgement. Antiembolic stockings should be applied after anticoagulation therapy is initiated.
D. Massage the client's affected leg twice a day: Massaging the affected leg is contraindicated in DVT as it can increase the risk of dislodging the clot, leading to complications such as pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An S3 heart sound is known as a ventricular gallop and occurs during the rapid filling phase of the ventricle in early diastole. It is commonly heard in conditions like heart failure, where the ventricles are overfilled, or in younger individuals with healthy hearts.
B. The closure of the pulmonic valve occurs at the end of systole and is associated with the second heart sound (S2), not S3.
C. An atrial gallop is represented by an S4 sound, which occurs just before S1 when the atria contract to fill the ventricles.
D. The closure of the mitral valve occurs during S1, not S3, and marks the beginning of systole.
Correct Answer is B
Explanation
A. Apply ice packs to affected leg: While ice can help reduce swelling and pain in some conditions, it is not typically recommended for deep vein thrombosis (DVT) because it could increase the risk of clot dislodgement.
B. Keep the client's affected leg elevated while in bed: Elevating the leg helps reduce swelling and promotes venous return, which is important in managing DVT.
C. Have the client ambulate prior to applying antiembolic stockings: Ambulation is usually avoided initially in the presence of DVT until anticoagulation therapy is started to reduce the risk of clot dislodgement. Antiembolic stockings should be applied after anticoagulation therapy is initiated.
D. Massage the client's affected leg twice a day: Massaging the affected leg is contraindicated in DVT as it can increase the risk of dislodging the clot, leading to complications such as pulmonary embolism.
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