The nurse has reviewed the Provider Prescriptions at 1600.

Exhibits
Which of the following interventions should the nurse implement for the client with deep vein thrombosis? Select all that apply.

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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Placing the cap sterile-side up on a clean surface prevents contamination of the inside of the cap and maintains the sterility of the solution. This step is essential before pouring to ensure the solution remains sterile.

B. Holding the bottle in the center of the sterile field risks contaminating the field if solution drips; the bottle should be held above or beside the field, not directly over it.

C. Placing sterile gauze over spilled solution does not restore sterility; contaminated areas must be replaced or discarded.

D. Holding the bottle with the label facing away from the palm helps protect the label, but it does not directly affect the sterility of the solution during pouring.

A. Place a pillow under the client's knees when changing positions. B. Use a sheet when repositioning the client onto his side. C. Apply an immobilizing collar on the client prior to movement. D. Instruct the client to keep his arms at his side when altering positions.

Correct Answer is B

Explanation

Rationale:

A. Place a pillow under the client's knees when changing positions: Elevating the knees with a pillow may be appropriate for comfort, but in a client with a thoracic spine injury, this can alter spinal alignment and increase the risk of further injury. Maintaining proper spinal alignment during all movements is more important than knee elevation.

B. Use a sheet when repositioning the client onto his side: Using a sheet for logrolling or turning helps maintain spinal alignment and allows multiple caregivers to move the client safely as a unit. This technique minimizes rotation or flexion of the spine, which is critical in preventing further spinal cord injury in clients with thoracic spine trauma.

C. Apply an immobilizing collar on the client prior to movement: Cervical collars are used for cervical spine injuries, not thoracic spine injuries. Applying a collar would not stabilize the thoracic spine and could give a false sense of security while performing repositioning.

D. Instruct the client to keep his arms at his side when altering positions: The client may need to assist in turning if possible, and keeping the arms rigidly at the side is not necessary. Restricting arm movement does not ensure spinal safety and may limit the client’s ability to participate safely in repositioning.

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The nurse has reviewed the Provider Prescriptions at 1600. Exhibits Which of the following interventions should the nurse implement for the client with deep vein thrombosis? Select all that apply.

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The nurse has reviewed the Provider Prescriptions at 1600.

Exhibits
Which of the following interventions should the nurse implement for the client with deep vein thrombosis? Select all that apply.