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Author Question: A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is the ... (Read 184 times)

lak

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A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is the priority outcome for this client?
 
  A) The client will not disturb the intravenous infusion.
  B) The client will comply with dietary restrictions.
  C) The client will not experience bleeding.
  D) The client will keep the right leg elevated on two pillows.

Question 2

The nurse is planning care for a client with deep venous thrombosis (DVT). Which nursing diagnosis would be a priority for this client?
 
  A) Risk for Infection related to obstructed venous return
  B) Excess Fluid Volume related to tissue edema
  C) Ineffective Tissue Perfusion related to obstructed venous return
  D) Disturbed Sleep Pattern related to tissue hypoxia



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ashely1112

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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.





 

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