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 {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"}}

Explanation

Rationale:

Sensation: Tingling indicates possible nerve irritation or mild neurovascular compromise. This is often seen in fractures when swelling or bone displacement compresses nerves near the injury site, especially in long bones like the radius.
Edema: Swelling is a nonspecific but common response to tissue injury. It occurs with ligament strain (sprain), bone disruption (fracture), and joint trauma (dislocation), all of which lead to localized inflammation and fluid accumulation.
Ecchymosis: Bruising results from soft tissue bleeding and is common in all three conditions due to trauma to blood vessels. Ligament tears (sprain), bone injury (fracture), and capsule damage (dislocation) can all lead to ecchymosis.
Pain level: Moderate pain, such as a 4/10 rating, is consistent with both sprains and fractures. Sprains stretch or tear ligaments, while fractures disrupt bone structure. Dislocations usually present with severe, sharp pain that impairs joint movement entirely.

A. Increased hemoglobin B. Increased urinary output C. Unilateral leg swelling D. Mild pain at the surgical site

Correct Answer is C

Explanation

Rationale:

A. Increased hemoglobin: A rise in hemoglobin is not expected after surgery but also does not suggest a postoperative complication. It may reflect hemoconcentration from mild dehydration or fluid shifts. This finding does not indicate infection, thrombosis, or impaired healing, so it is not a priority concern at this stage.

B. Increased urinary output: Higher urinary output may occur if the client is well-hydrated or receiving IV fluids. This finding does not suggest renal impairment or postoperative complications. As long as urine is clear and the client is stable, increased output is not concerning and requires only routine monitoring.

C. Unilateral leg swelling: One-sided leg swelling is a hallmark sign of deep vein thrombosis, a serious complication after pelvic surgery due to venous stasis and immobilization. A DVT can progress to pulmonary embolism, posing immediate danger. The finding requires prompt evaluation and intervention to prevent life-threatening complications.

D. Mild pain at the surgical site: Mild incisional pain is expected on postoperative day three as tissues heal and inflammation decreases. This finding is typical and manageable with analgesics. As long as pain is not severe or accompanied by fever, redness, or purulent drainage, it does not indicate a complication.

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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

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"}}

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.