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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Correct Answer is ["B","C","E"]

Explanation

Rationale:

A. Anemia: While anemia affects oxygen delivery and overall health, it is not a direct risk factor for neonatal hypoglycemia. Anemia does not significantly impact the infant’s glucose regulation immediately after birth.

B. Prematurity: Premature infants have limited glycogen stores, immature liver function, and underdeveloped metabolic pathways, making them more prone to hypoglycemia. Their ability to maintain normal blood glucose levels is compromised, increasing the risk of low glucose after birth.

C. Maternal diabetes: Infants born to mothers with diabetes are exposed to high glucose levels in utero, which stimulates fetal insulin production. After birth, this hyperinsulinemia can lead to rapid drops in blood glucose, placing the newborn at high risk for hypoglycemia.

D. Thrombocytopenia: Low platelet count affects coagulation but does not directly influence glucose metabolism or the risk of hypoglycemia in newborns. While it is a clinical concern, it is unrelated to neonatal glucose regulation.

E. Hypothermia: Cold stress increases metabolic demands and glucose utilization in newborns. Hypothermia can accelerate depletion of glycogen stores and impair gluconeogenesis, making it a significant risk factor for hypoglycemia in the neonatal period.

A. Disulfiram B. Naloxone C. Activated charcoal D. Flumaren

Correct Answer is B

Explanation

Rationale:

A. Disulfiram: Disulfiram is used to support alcohol abstinence by causing unpleasant reactions when alcohol is consumed. It does not reverse opioid overdose and is not indicated for morphine toxicity.

B. Naloxone: Naloxone is an opioid antagonist that binds to opioid receptors and rapidly reverses the effects of morphine and other opioids. It is the first-line treatment for opioid overdose, effectively restoring respiratory function and alertness.

C. Activated charcoal: Activated charcoal can adsorb certain ingested toxins in the gastrointestinal tract, but it is not effective for opioids already absorbed systemically, such as in a morphine overdose.

D. Flumaren: Flumazenil (Flumaren) is a benzodiazepine antagonist used to reverse benzodiazepine overdose, not opioid toxicity. It has no effect on morphine or other opioids.

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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.

Nursing Test Bank

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Explanation

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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.