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 B

Explanation

Choice A reason: Administering an antacid relieves epigastric pain but is premature without assessing pain characteristics. Pain in peptic ulcer disease may indicate complications like perforation, requiring urgent evaluation. Assessment guides whether antacids or other interventions are appropriate, prioritizing patient safety.

Choice B reason: Assessing pain characteristics (e.g., location, intensity, radiation) is the first step, as epigastric pain in peptic ulcer disease may signal complications like bleeding or perforation. This data guides interventions, ensuring timely management of potentially life-threatening conditions, making it the priority action.

Choice C reason: Checking NSAID use identifies ulcer triggers but is secondary to pain assessment. Pain characteristics determine urgency, as severe or radiating pain may indicate perforation, requiring immediate action. Assessment provides critical data before investigating contributing factors like medication history.

Choice D reason: Obtaining a stool sample for occult blood detects gastrointestinal bleeding but is not the first step. Assessing pain characteristics identifies urgent complications like perforation, guiding whether diagnostic tests or interventions are needed, making pain assessment the initial priority.

A. Apply warm compresses to affected joints B. Restrict all physical activity C. Administer high-dose corticosteroids D. Encourage high-sodium diet

Correct Answer is A

Explanation

Choice A reason: Warm compresses reduce morning stiffness in rheumatoid arthritis by increasing blood flow and relaxing muscles around inflamed joints. This alleviates synovial inflammation, improving mobility and comfort, making it a key nonpharmacologic intervention to manage early daily symptoms effectively.

Choice B reason: Restricting physical activity worsens stiffness and joint deformity in rheumatoid arthritis. Warm compresses are prioritized, as they directly reduce synovial inflammation and improve mobility, enabling gentle exercise, making complete activity restriction counterproductive to joint health and function.

Choice C reason: High-dose corticosteroids are reserved for severe rheumatoid arthritis flares, not routine morning stiffness. Warm compresses are safer, reducing stiffness through localized heat, improving joint function without systemic side effects, making them the priority intervention for daily symptom management.

Choice D reason: A high-sodium diet increases fluid retention, potentially worsening joint inflammation in rheumatoid arthritis. Warm compresses directly alleviate morning stiffness by enhancing circulation, making them the priority, as dietary sodium does not address acute joint symptoms effectively.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?

Correct Answer is B

Explanation

The nurse is caring for a client with a history of rheumatoid arthritis who reports morning stiffness. Which intervention should the nurse include?

Correct Answer is A

Explanation

The nurse is caring for a client with a suspected stroke. Which intervention should the nurse prioritize?

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