A patient with spinal cord injury has altered-mobility, which increases the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent DVT formation?

Applying a sequential compression device

Administering an antifibrinolytic agent

Placing the patient on a fluid restriction

Assisting the patient with passive ROM exercises

Answer and Explanation

The Correct Answer is A

A. Applying a sequential compression device. – Correct Answer. SCDs help prevent venous stasis, reducing the risk of DVT in immobile patients.

B. Administering an antifibrinolytic agent. – Incorrect. Antifibrinolytics promote clot formation and are used for bleeding disorders, not DVT prevention.

C. Placing the patient on a fluid restriction. – Incorrect. Adequate hydration is important to prevent blood viscosity and clot formation.

D. Assisting the patient with passive ROM exercises. – Incorrect. Passive ROM helps circulation, but SCDs provide more effective DVT prevention.

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Correct Answer is A

Explanation

A. Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes – These findings indicate improved hydration, resolution of hyperosmolarity, and recovery of neurological function, key markers of HHS improvement.

B. Alert and oriented, balanced intake and output, moist mucous membranes – While improved hydration is good, ketone clearance and hemodynamic stability are more important indicators.

C. Respirations easy and unlabored, eats 50-75% of meals, vital signs stable – Respiratory status is not the primary concern in HHS.

D. Equal intake and output, denies pain or shortness of breath – These signs do not specifically indicate resolution of HHS.

A. Regular and Humulin N B. Regular and Novolin N C. Lantus and Humulin N D. Humulin R and Novolin N

Correct Answer is C

Explanation

A. Incorrect. Regular insulin (short-acting) and Humulin N (intermediate-acting) can be mixed.

B. Incorrect. Regular insulin and Novolin N are compatible.

C. Correct. Lantus (glargine) is a long-acting insulin that should never be mixed with other insulins.

D. Incorrect. Humulin R (short-acting) and Novolin N (intermediate-acting) can be mixed.

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A patient with spinal cord injury has altered-mobility, which increases the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent DVT formation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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