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 D

Explanation

Rationale:

A. "The care team will discuss how to change the DNR prescription.": While discussions about code status may occur, the care team cannot override the client’s documented wishes. Focusing on changing the DNR for the family disregards the ethical and legal principle of patient autonomy.

B. "I will ask the client's provider to change the prescription.": The provider cannot unilaterally change a DNR order without the client’s consent. Doing so would violate the client’s legal rights and established advance directive.

C. "A family member can change a DNR prescription once it has been signed.": Only the client has the authority to modify or revoke a DNR unless the client is incapacitated and has legally designated a healthcare proxy. Family members do not have the right to override the client’s documented wishes arbitrarily.

D. "These are the client's wishes, and we must respect them.": The nurse’s response acknowledges the ethical and legal obligation to honor the client’s autonomy. DNR orders reflect the client’s informed decisions about life-sustaining treatments, which must be respected even if family members disagree.

A. 61-year-old male B. Has smoked 1 pack of cigarettes per day for 40 years. C. History of hyperlipidemia. D. Walks at least a mile three times a week. E. Reports drinking two to three beers each evening F. Client reports he follows the Dietary Approaches to Stop Hypertension (DASH) diet. G. Biological father has a history of hyperlipidemia and hypertension. H. Biological mother has history of renal failure requiring dialysis. I. BMI 30.5

Correct Answer is ["A","B","C","E","G","H","I"]

Explanation

Rationale for correct choices

• 61-year-old male: Advanced age and male sex increase the risk of cardiovascular complications such as coronary artery disease, heart failure, and stroke. Aging contributes to arterial stiffness, reduced cardiac reserve, and higher likelihood of comorbidities, all of which elevate the risk profile for this client.

• Has smoked 1 pack of cigarettes per day for 40 years: Chronic smoking is a major modifiable risk factor for atherosclerosis, myocardial infarction, stroke, and peripheral arterial disease. Long-term tobacco use promotes endothelial damage, increases LDL cholesterol, and impairs oxygen delivery, significantly increasing cardiovascular risk.

• History of hyperlipidemia: Elevated cholesterol and triglycerides predispose the client to plaque formation in arteries, contributing to atherosclerosis and cardiovascular disease. Hyperlipidemia is a key risk factor for complications such as myocardial infarction and stroke, especially when combined with other comorbidities.

• Reports drinking two to three beers each evening: Excessive alcohol consumption contributes to hypertension, cardiomyopathy, and arrhythmias. Chronic alcohol intake can also exacerbate hyperlipidemia and increase the risk of liver disease, compounding cardiovascular and systemic complications.

• BMI 30.5: A BMI above 30 classifies the client as obese, which increases the risk for hypertension, type 2 diabetes, heart disease, and stroke. Obesity contributes to metabolic syndrome and further stresses the cardiovascular system, making the client more prone to complications.

• Family history: Biological father with hyperlipidemia and hypertension, Biological mother with renal failure: A strong family history of cardiovascular and renal disease increases the client’s genetic susceptibility to these conditions. Inherited risk factors, when combined with lifestyle factors, significantly elevate the likelihood of developing complications such as heart failure, chronic kidney disease, or stroke.

Rationale for incorrect choices

• Walks at least a mile three times a week: Regular physical activity is protective, not a risk factor, for cardiovascular and metabolic complications. Exercise helps improve lipid profile, blood pressure, and overall cardiovascular health, mitigating some of the client’s other risk factors.

• Client reports he follows the DASH diet: Adhering to the DASH diet is a positive lifestyle behavior that reduces blood pressure, supports heart health, and lowers the risk of stroke or heart disease. It is not a risk factor; rather, it is a mitigating factor against cardiovascular complications.

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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

A nurse is caring for a client who is being treated for acute opioid toxicity. The client has a do-not-resuscitate (DNR) prescription, but the family would like to remove it. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

Correct Answer is ["A","B","C","E","G","H","I"]

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.