A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take?
Apply a cold compress to the affected extremity.
Teach the client to massage the affected extremity.
Instruct the client to elevate the affected extremity when sitting.
Assess pulses proximal to the affected area.
The Correct Answer is C
Rationale:
A. Applying a cold compress is not recommended for DVT; instead, heat may be more appropriate to alleviate discomfort and improve circulation.
B. Massaging the affected extremity is contraindicated as it can dislodge the clot and lead to complications such as pulmonary embolism.
C. Instructing the client to elevate the affected extremity helps reduce swelling and promote venous return, making it the best action.
D. Assessing pulses proximal to the affected area is important for monitoring circulation, but it is not the primary intervention for managing DVT.
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Correct Answer is B
Explanation
Rationale:
A. Attaching the NG tube to low intermittent suction is not recommended during gastric lavage, as suctioning can remove the lavage solution before it has a chance to work effectively.
B. Instilling the lavage solution in volumes of 500 mL at a time is correct as it allows for effective cleansing of the stomach and can help to clear out any blood or debris present.
C. Chilled lavage solution should not be used; it is recommended to use room temperature or warmed solution to avoid discomfort and potential complications such as cramping.
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Correct Answer is C
Explanation
Rationale:
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B. Urinary retention can occur but is not a common initial symptom associated with ovarian cancer.
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