A client being treated for a deep venous thrombosis (DVT) is ...

[Chloeellawright]

A client being treated for a deep venous thrombosis (DVT) is experiencing pain. Which interventions by the nurse are appropriate to assist this client?
 
  Select all that apply.
  A) Apply an egg-crate mattress on the bed.
  B) Maintain bed rest as ordered.
  C) Apply warm moist heat to the area four times a day.
  D) Encourage position changes every 2 hours.
  E) Measure calf and thigh diameter daily.

Question 2

A client receiving heparin therapy for deep venous thrombosis (DVT) complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, which is the priority action by the nurse?
 
  A) Assess pulse, respirations, and blood pressure.
  B) Apply oxygen and elevate the head of the bed.
  C) Reassure the client and notify family members.
  D) Increase the rate of heparin infusion.

[Dinolord]

Answer to Question 1

Answer: B, C, E

Interventions to address pain include applying warm moist heat to the area four times a day, maintaining bed rest as ordered, and measuring calf and thigh diameter daily. Applying an egg-crate mattress on the bed and encouraging position changes every 2 hours would be appropriate for the client experiencing Ineffective Tissue Perfusion.

Answer to Question 2

Answer: B

Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing the rate of heparin infusion cannot be done by the nurse without an order from a healthcare provider. Reassuring the client and notifying family members are not priorities, although these measures can decrease the client's anxiety; the priority is to begin oxygen therapy and elevate the head of the bed to increase oxygenation to the tissues. Assessing pulse, respiration, and blood pressure will be performed following the initiation of oxygen therapy and bed elevation.