The nurse is caring for a client with a history of deep vein thrombosis. Which intervention should the nurse include in the care plan?
Encourage early ambulation
Apply warm compresses to the leg
Restrict fluid intake
Elevate the affected leg
The Correct Answer is D
Choice A reason: Early ambulation prevents stasis but is contraindicated in acute deep vein thrombosis, as it risks dislodging the clot, causing pulmonary embolism. Leg elevation reduces swelling and promotes venous return, making it the priority intervention to manage acute DVT safely.
Choice B reason: Warm compresses may increase blood flow but are not standard for deep vein thrombosis, as they risk clot dislodgement. Leg elevation reduces edema and venous pressure, improving circulation without mobilizing the clot, making it the preferred intervention for DVT management.
Choice C reason: Restricting fluid intake is inappropriate, as hydration prevents blood viscosity increases that exacerbate deep vein thrombosis. Leg elevation directly reduces swelling and promotes venous return, addressing the primary issue of venous stasis, making it the priority over fluid restriction.
Choice D reason: Elevating the affected leg reduces edema and venous pressure in deep vein thrombosis by promoting venous return to the heart. This decreases clot propagation risk and alleviates pain, making it a key intervention to manage acute DVT effectively and prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Using a bronchodilator for sudden shortness of breath applies to rescue inhalers like albuterol, not maintenance bronchodilators (e.g., tiotropium) for COPD, which are used daily. This statement indicates misunderstanding, as maintenance inhalers prevent symptoms, not treat acute dyspnea.
Choice B reason: Thinner sputum is not a primary effect of bronchodilators, which relax airway smooth muscles to improve airflow in COPD. Mucolytics, not bronchodilators, reduce sputum viscosity. This statement reflects incorrect understanding, as bronchodilators target bronchoconstriction, not secretion consistency.
Choice C reason: Daily use of a maintenance bronchodilator, like tiotropium, is correct for COPD to prevent bronchospasm and maintain airway patency. This statement shows proper understanding, as consistent use reduces exacerbations and improves lung function, aligning with standard COPD management protocols.
Choice D reason: Using another inhaler between doses suggests confusion about maintenance versus rescue inhalers. Maintenance bronchodilators are used daily, not interspersed with others. This indicates misunderstanding, as proper scheduling is essential for effective COPD control with prescribed bronchodilators.
Correct Answer is A
Explanation
Choice A reason: Monitoring daily urine output assesses kidney function and fluid balance, as urine volume reflects hydration and electrolyte homeostasis. Inadequate output signals dehydration or renal issues, allowing timely intervention to maintain fluid and electrolyte balance, making it the most effective nursing action.
Choice B reason: Salt tablets after exercise replace sodium lost in sweat but are not a universal intervention for fluid and electrolyte balance. They risk hypernatremia if overused. Monitoring urine output is more comprehensive, as it directly evaluates fluid status across various clinical scenarios.
Choice C reason: Reviewing food labels for sodium content helps manage dietary intake but is indirect and patient-dependent. Urine output monitoring provides objective data on fluid and electrolyte status, enabling timely adjustments in therapy, making it a more immediate and reliable intervention.
Choice D reason: Drinking water when thirsty supports hydration but relies on subjective thirst, which may be impaired in certain conditions. Monitoring urine output objectively assesses fluid balance, detecting imbalances early, making it a more proactive and precise intervention than thirst-driven hydration.
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