A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?

Elevate the affected leg.

Place cold compresses on the edematous area.

Restrict the client to 1 L of fluid per day.

Maintain the client on bed rest.

Answer and Explanation

The Correct Answer is A

A. Elevating the affected leg is an important intervention for reducing swelling and promoting venous return, which can help alleviate discomfort and prevent further complications.

B. Placing cold compresses on the edematous area may provide temporary relief but is not a standard intervention for deep-vein thrombosis and could potentially harm tissue if applied for too long.

C. Restricting the client to 1 L of fluid per day is inappropriate, as adequate hydration is essential for maintaining good venous health and preventing further complications.

D. Maintaining the client on bed rest is not necessary; while rest is important, early ambulation is encouraged to promote circulation and prevent further clot formation unless contraindicated.

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Correct Answer is D

Explanation

A. Encouraging friends and family to visit the child is not appropriate due to the risk of infections, as the child has a severely compromised immune system.

B. A low-protein diet is not indicated; children with leukemia often require adequate nutrition to support their health.

C. Collecting a daily urine specimen for proteinuria is not specifically indicated for this condition; the focus should be on infection prevention.

D. Withholding the varicella vaccine is essential because live vaccines are contraindicated in immunocompromised patients due to the risk of severe infections.

A. Assess the client's IV site every 8 hr. B. Check the client's WBC count every 48 hr. C. Monitor the client's mouth every 8 hr. D. Change the client's tubing every 48 hr.

Correct Answer is A

Explanation

A. Assessing the client's IV site every 8 hours is appropriate to prevent complications such as infection or infiltration, especially in an immunocompromised client.

B. Checking the client's WBC count every 48 hours is insufficient; it should be monitored more frequently due to the client's immunocompromised state.

C. Monitoring the client's mouth every 8 hours is necessary, but not as critical as regular IV site assessments.

D. Changing the client's tubing every 48 hours may not be necessary unless indicated by the facility's protocol or the client's condition; continuous IV tubing is typically changed every 72 to 96 hours unless there are signs of complications.

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A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?

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