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.
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Related Questions
Correct Answer is C
Explanation
A. While bile and pancreatic enzymes play a role in digestion, dumping syndrome is not related to an increase in their secretion.
B. Dumping syndrome is not caused by an inability to digest high-fat foods, but rather by the rapid passage of undigested food into the small intestine, which can cause symptoms like nausea, dizziness, and diarrhea.
C. Dumping syndrome occurs when food, especially sugar, moves too quickly from the stomach into the small intestine, overwhelming the digestive system. This leads to symptoms like abdominal cramping, dizziness, and diarrhea.
D. Dumping syndrome is not related to insulin secretion; it is more about the rapid emptying of food into the small intestine.
Correct Answer is B
Explanation
A. Furosemide is a loop diuretic that primarily causes hypokalemia (low potassium levels) and does not typically cause hyperkalemia. It can also cause dehydration and hyponatremia, but it is not associated with both hyperkalemia and hyponatremia.
B. Spironolactone is a potassium-sparing diuretic. It helps retain potassium while excreting sodium and water, which increases the risk for hyperkalemia (high potassium) and hyponatremia (low sodium) when used in combination with other medications that affect electrolyte balance.
C. Metolazone is a thiazide-like diuretic that can cause hypokalemia and hyponatremia, but it is not typically associated with hyperkalemia.
D. Hydrochlorothiazide is a thiazide diuretic that can cause hypokalemia and hyponatremia, but it does not increase the risk of hyperkalemia.
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