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 B

Explanation

A. S3 heart sound: An S3 heart sound is often associated with heart failure and volume overload, not specifically mitral stenosis.

B. Dyspnea on exertion: Dyspnea on exertion is a classic symptom of mitral stenosis. The narrowing of the mitral valve restricts blood flow from the left atrium to the left ventricle, causing pulmonary congestion and shortness of breath, especially during physical activity.

C. Cyanosis: While cyanosis can occur in advanced stages of heart disease, it is not a primary symptom of mitral stenosis. It indicates severe oxygenation issues, which are usually late findings.

D. S4 heart sound: An S4 heart sound is typically associated with left ventricular hypertrophy, which can occur in advanced cases of mitral stenosis. However, it's not a specific early manifestation of the condition.

A. Obtain a pair of slipper socks for the client. B. Increase the client's oral fluid intake. C. Place a moist heating pad under the client's feet. D. Rub the client's feet briskly for several minutes.

Correct Answer is A

Explanation

A. Obtain a pair of slipper socks for the client. This is an appropriate action. Slipper socks can provide warmth and help improve circulation, promoting comfort.

B. Increase the client's oral fluid intake. While hydration is important for overall health, it will not directly address the cold feet caused by poor circulation in this scenario.

C. Place a moist heating pad under the client's feet. Heating pads, especially moist ones, can increase the risk of burns and should be avoided in clients with vascular occlusions, as they may have decreased sensation.

D. Rub the client's feet briskly for several minutes. Rubbing the feet briskly could cause skin breakdown and injury due to fragile skin and impaired circulation.

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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

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Correct Answer is A

Explanation

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