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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Chest x-ray may show nonspecific findings in pulmonary embolism but is not diagnostic. D-dimer, a fibrin degradation product, is highly sensitive for detecting thrombosis, guiding further imaging like CT pulmonary angiography, making it the priority test in suspected cases.

Choice B reason: Electrocardiogram may show tachycardia or right heart strain in pulmonary embolism but is nonspecific. D-dimer is a sensitive screening test, indicating clot presence, which prompts definitive imaging, making it the preferred initial diagnostic step in suspected pulmonary embolism.

Choice C reason: D-dimer blood test is the most sensitive screening tool for pulmonary embolism, detecting fibrin degradation from clots. Elevated levels prompt CT pulmonary angiography for confirmation, guiding urgent treatment to prevent further embolization, making it the critical test to anticipate.

Choice D reason: Arterial blood gas may reveal hypoxemia in pulmonary embolism but is nonspecific, as other conditions cause similar findings. D-dimer is more diagnostic, identifying clot presence, guiding imaging, and ensuring timely intervention, making it the priority test in suspected cases.

A. Increased urine output B. Elevated blood pressure C. Increased heart rate D. Weight gain

Correct Answer is A

Explanation

Choice A reason: Furosemide, a loop diuretic, promotes urine output by inhibiting sodium reabsorption in the kidneys, reducing fluid overload in heart failure. Increased urine output indicates effective diuresis, alleviating pulmonary and peripheral edema, making it the primary sign of therapeutic efficacy.

Choice B reason: Elevated blood pressure is not an expected effect of furosemide, which reduces preload and blood volume, often lowering pressure. Effective diuresis is shown by increased urine output, as this directly reflects fluid removal, critical for heart failure management.

Choice C reason: Increased heart rate is not a direct indicator of furosemide efficacy. Diuresis reduces cardiac workload, potentially stabilizing heart rate, but urine output is the primary measure, as it confirms fluid excretion, the medication’s main action in heart failure.

Choice D reason: Weight gain indicates fluid retention, the opposite of furosemide’s goal. Effective diuresis causes weight loss due to fluid excretion. Increased urine output is the key sign, as it directly measures the diuretic’s action in reducing heart failure-related fluid overload.

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The nurse is caring for a client with a history of deep vein thrombosis. Which intervention should the nurse include in the care plan?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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