Which of the following interventions is contraindicated in a patient with deep vein thrombosis of the right leg?

Appeared in: KPSC Staff Nurse - 2016

Explanation

The intervention that is contraindicated is ambulation in the hall.
In the acute phase of DVT, physical activity like walking can cause the blood clot to dislodge from the vein wall.
A dislodged clot can travel to the lungs, leading to a potentially fatal pulmonary embolism (PE).
Bed rest is typically maintained until the patient has received anticoagulant therapy for a sufficient time to stabilize the clot, reducing the risk of embolization.

Option A: Elevation of the limb is an indicated and beneficial intervention for DVT.
Option B: Application of moist heat is a recommended comfort measure for DVT.
Option D: Administration of analgesics is an appropriate intervention for a patient with DVT.

Clinical Relevance

Nursing practice connection: Use the key finding related to Management of Deep Vein Thrombosis (DVT) to guide bedside assessment, documentation, and the next nursing action.
The nurse's primary role in managing acute DVT is patient safety, focusing on preventing a pulmonary embolism.
Nurses must educate the patient on the importance of bed rest and limb elevation and explain the rationale to ensure compliance.
Key nursing assessments include monitoring for signs of PE (e.g., sudden shortness of breath, chest pain, tachycardia) and observing for signs of bleeding once anticoagulant therapy is initiated.

How to Approach the Question

First, identify the key terms in the question: "contraindicated" and "deep vein thrombosis (DVT)". This means you are looking for an action that should NOT be performed.
Next, consider the pathophysiology of DVT. The main danger is the blood clot breaking off and traveling to the lungs (pulmonary embolism).
Evaluate each option based on this risk. Ask yourself, "Could this action dislodge the clot?"
Analyze the options: Elevation helps blood flow back to the heart and reduces swelling. Moist heat is a comfort measure. Analgesics manage pain.
Consider ambulation: Walking involves muscle contractions in the legs, which could squeeze the vein and dislodge the fresh, unstable clot.
Conclude that ambulation poses the greatest risk and is therefore the contraindicated intervention in the acute phase.

Concept Tested & Keywords

Qy7gIkPH8PptUVUb5my-bB

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 3 p. 80-82

Practise the full KPSC Staff Nurse - 2016

Attempt every question from this paper in a timed mock, then review the full solution for each one.