The nurse has reviewed the Provider Prescriptions at 1600.
Encourage the client to elevate their legs while in bed.
Place an immobilizer on the affected leg.
Implement bleeding precautions.
Apply intermittent pneumatic compression devices to the unaffected leg.
Instruct the client to expect dark stools.
Correct Answer : A,C,D
Rationale:
A. Encourage the client to elevate their legs while in bed: Elevating the affected leg helps reduce venous pressure, decreasing edema and discomfort associated with DVT. Elevation also promotes venous return, which can limit further clot propagation. This intervention provides symptom relief without increasing the risk of embolization.
B. Place an immobilizer on the affected leg: Immobilizers restrict movement and are used for musculoskeletal injuries, not for DVT management. Immobilization can worsen venous stasis by reducing circulation in the lower extremity. Instead, clients with DVT benefit from gentle mobility once anticoagulation is initiated, unless contraindicated, to prevent worsening clot burden.
C. Implement bleeding precautions: The client has diagnostic confirmation of DVT and will require anticoagulation, which increases bleeding risk. Bleeding precautions help prevent complications such as hematuria, bruising, or gastrointestinal bleeding. Monitoring for signs of bleeding and avoiding trauma are essential once therapy begins.
D. Apply intermittent pneumatic compression devices to the unaffected leg: IPC devices should not be applied to the affected limb due to the risk of dislodging the thrombus. However, using them on the unaffected leg promotes venous return and helps prevent additional clot formation.
E. Instruct the client to expect dark stools: Dark stools can indicate gastrointestinal bleeding, which is not an expected effect of DVT treatment. While anticoagulants can increase bleeding risk, the nurse should teach the client to report black or tarry stools immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Banana slices: Soft, manageable, and cut into small pieces, banana slices are safe for a toddler to pick up and self-feed. They promote fine motor skill development and independence while minimizing the risk of choking.
B. Popcorn: Popcorn is a choking hazard for toddlers because it is small, hard, and easily inhaled. It is unsafe for children under 4 years and should be avoided when promoting independent eating.
C. Grapes: Whole grapes are also a significant choking risk. If given, they must be cut into small, manageable pieces, so serving them whole does not support safe independent eating.
D. Hot dog: Whole hot dogs are cylindrical and firm, posing a high choking risk for toddlers. Even when sliced lengthwise or chopped, supervision is required, and they are less suitable for promoting safe self-feeding compared to soft fruits like banana slices.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Rationale for correct choices
• Report to the provider immediately if a dry cough develops: ACE inhibitors or similar antihypertensive medications can cause a persistent dry cough as a side effect. Early reporting allows the provider to evaluate the need for medication adjustment or substitution to prevent further complications, such as noncompliance or worsening respiratory symptoms.
• Report to the provider immediately if the client experiences muscle aches: Muscle aches or myalgia can indicate statin-induced myopathy or rhabdomyolysis, particularly with elevated LDL and prescription of statins such as rosuvastatin. Early detection prevents severe muscle breakdown, renal impairment, or other complications.
Rationale for incorrect choices
• Increase sodium intake: The client has hypertension, and increasing sodium intake would exacerbate elevated blood pressure and increase the risk of cardiovascular complications, including heart failure and stroke. Sodium restriction is essential to support blood pressure control and overall cardiovascular health.
• Take rosuvastatin only in the morning: Rosuvastatin can be taken at any time of day, unlike some other statins that are recommended in the evening. Restricting it to the morning is unnecessary and may reduce adherence if it conflicts with the client’s routine. Emphasis should be on consistent daily intake rather than timing.
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