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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Ensuring adequate nutrition is important, but the priority is preventing aspiration, as the client may have difficulty swallowing or clearing the airway due to the intermaxillary fixation. Aspiration could lead to serious complications like pneumonia.
B. Preventing aspiration is the priority because the client may have difficulty swallowing or controlling their airway due to the surgical procedure and fixation of the jaw. The nurse should ensure the client's airway is clear and that they are positioned appropriately to prevent aspiration.
C. Pain relief is important for comfort and recovery, but it is secondary to ensuring the client's airway is protected and preventing aspiration, which could lead to more severe complications.
D. Promoting oral hygiene is important, but it is not the priority in the immediate postoperative period. The focus should be on ensuring the airway is clear and preventing aspiration, especially if the client is unable to properly swallow or manage secretions.

A. Analgesic B. Anti-inflammatory C. Antiplatelet aggregate D. Antipyretic

Correct Answer is C

Explanation

A. While aspirin has analgesic properties, it is not primarily used for pain relief in the case of myocardial infarction (MI). Its main role in MI is to reduce the risk of further clot formation.
B. Aspirin has anti-inflammatory properties, but in the case of MI, its primary role is not inflammation reduction but rather preventing platelet aggregation.
C. Aspirin acts as an antiplatelet aggregate, which is its key action in preventing the formation of blood clots. This is crucial for patients with a history of MI, as it helps reduce the risk of further clot-related events, such as a recurrent MI or stroke.
D. Aspirin does have antipyretic effects, but this is not the primary reason for its use in MI.

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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?

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