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    Ati Rn Comprehensive Predictor Proctored Exam 2023
    Select All That Apply

    The nurse has reviewed the Provider Prescriptions at 1600. Exhibits Which of the following interventions should the nurse implement for the client with deep vein thrombosis? Select all that apply.

    Explanation & Rationale

    Rationale: A. Encourage the client to elevate their legs while in bed: Elevating the affected leg helps reduce venous pressure, decreasing edema and discomfort associated with DVT. Elevation also promotes venous return, which can limit further clot propagation. This intervention provides symptom relief without increasing the risk of embolization. B. Place an immobilizer on the affected leg: Immobilizers restrict movement and are used for musculoskeletal injuries, not for DVT management. Immobilization can worsen venous stasis by reducing circulation in the lower extremity. Instead, clients with DVT benefit from gentle mobility once anticoagulation is initiated, unless contraindicated, to prevent worsening clot burden. C. Implement bleeding precautions: The client has diagnostic confirmation of DVT and will require anticoagulation, which increases bleeding risk. Bleeding precautions help prevent complications such as hematuria, bruising, or gastrointestinal bleeding. Monitoring for signs of bleeding and avoiding trauma are essential once therapy begins. D. Apply intermittent pneumatic compression devices to the unaffected leg: IPC devices should not be applied to the affected limb due to the risk of dislodging the thrombus. However, using them on the unaffected leg promotes venous return and helps prevent additional clot formation. E. Instruct the client to expect dark stools: Dark stools can indicate gastrointestinal bleeding, which is not an expected effect of DVT treatment. While anticoagulants can increase bleeding risk, the nurse should teach the client to report black or tarry stools immediately.

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