The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk?
A) Encourage independence with ADLs whenever possible.
B) Monitor the patient's nutritional status closely.
C) Teach the patient to perform ankle and foot exercises within the limitations of traction.
D) Administer clopidogrel (Plavix) as ordered.
Ans: C
Feedback:
The nurse educates the patient how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. Nutrition is important, but does not directly prevent DVT. Similarly, independence with ADLs should be promoted, but this does not confer significant prevention of DVT, which often affects the lower limbs. Plavix is not normally used for DVT prophylaxis.
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