A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?

Limit movement of the lower extremities.

Place sequential compression devices bilaterally.

Massage lower extremities daily.

Check for negative Homans' sign.

Answer and Explanation

The Correct Answer is B

A. Limit movement of the lower extremities. Limiting movement increases the risk of venous stasis, which can lead to DVT. Regular movement and ambulation are encouraged to promote blood circulation.

B. Place sequential compression devices bilaterally. Sequential compression devices (SCDs) help promote venous return and prevent venous stasis, thereby reducing the risk of DVT.

C. Massage lower extremities daily. Massaging the legs is contraindicated in clients at risk for DVT because it can dislodge a clot and lead to pulmonary embolism.

D. Check for negative Homans' sign. The Homans' sign (pain in the calf on dorsiflexion of the foot) is not a reliable indicator of DVT and is no longer recommended as a standard assessment method.

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Correct Answer is C

Explanation

A. Obtain a blood sample. While obtaining a blood sample to check cardiac enzyme levels is important for diagnosing myocardial injury, it is not the priority over oxygen therapy, given the client’s shortness of breath and cyanosis.

B. Insert the IV catheter. IV access is important for administering fluids and medications, but it is not the first priority in this scenario where the client is experiencing respiratory distress.

C. Initiate oxygen therapy. The client shows signs of hypoxia (shortness of breath and cyanosis), and oxygen is crucial for stabilizing oxygen levels and preventing further deterioration of cardiac and respiratory function.

D. Attach the leads for a 12-lead ECG. Attaching the leads for an ECG is essential to evaluate the client's cardiac status, but it is not the most urgent action in the presence of cyanosis and respiratory distress.

A. Tell the client to take another nitroglycerin tablet in 15 min. B. Advise the client to take an antacid. C. Advise the client to come into the office. D. Instruct the client to call 911.

Correct Answer is D

Explanation

A. Tell the client to take another nitroglycerin tablet in 15 minutes. Nitroglycerin can be taken every 5 minutes, up to three doses, for chest pain. Waiting 15 minutes to take another dose is too long and can delay necessary treatment.

B. Advise the client to take an antacid. Antacids are not appropriate for managing chest pain that may be related to angina or a myocardial infarction. This response may delay critical treatment.

C. Advise the client to come into the office. This would delay care in a potential emergency situation. If the client is experiencing unrelieved chest pain after taking nitroglycerin, immediate emergency care is necessary.

D. Instruct the client to call 911. Chest pain unrelieved by nitroglycerin is a sign of a possible myocardial infarction, which is a medical emergency. The client should call 911 immediately to receive urgent care.

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A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

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