A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis of the left leg. Which of the following interventions should the nurse include in the plan?
Explanation & Rationale
Choice A reason: Monitoring platelet levels is essential in a client with deep vein thrombosis receiving anticoagulants like heparin, as low platelets (heparin-induced thrombocytopenia) increase bleeding or clotting risks. This ensures safe therapy, making it the correct intervention to include in the care plan for effective management. Choice B reason: Restricting oral fluids is contraindicated in deep vein thrombosis, as dehydration increases blood viscosity, worsening clot risk. Adequate hydration promotes circulation, making this incorrect, as the nurse should encourage fluid intake, not restriction, to prevent further thrombosis in the client. Choice C reason: Applying ice is not standard for deep vein thrombosis, which benefits from warmth to promote circulation and reduce swelling. Ice may worsen stasis, making this incorrect, as the nurse should prioritize interventions like anticoagulation monitoring over inappropriate temperature therapies for this condition. Choice D reason: Vasodilating medications are not used for deep vein thrombosis, which requires anticoagulants to prevent clot progression. Vasodilation does not address thrombosis, making this incorrect, as monitoring platelets is more relevant to ensure safe anticoagulant therapy in managing the client’s condition.