Answer to Question 1
Answer: C
An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy. Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding. Elevation of the affected extremity is important but not as high a priority as an absence of bleeding.
Answer to Question 2
Answer: C
Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis because it identifies the underlying cause. Excess Fluid Volume related to tissue edema and Disturbed Sleep Pattern related to tissue hypoxia are incorrect because they do not identify the underlying cause. Risk for Infection related to obstructed venous return would be a priority if complications of infection were present, however this is not the case.
A nurse adjusts the rate of a client’s IV.
Continuous positive airway pressure (CPAP) device. The sleeping subject is receiving the benefits of
Deep venous thrombosis.
A patient with Cushing’s syndrome (A) before and (B) after receiving treatment. Sharmyn McGraw
Deep palpation