Which one of the following interventions should be avoided by the nurse while caring for a client with deep vein thrombosis?

Appeared in: SCTIMST Staff Nurse - 2015 (Set-A)

Explanation

Massaging the extremity with a known or suspected DVT is strictly contraindicated.
The mechanical pressure from massage can dislodge the thrombus from the vein wall.
A dislodged clot (embolus) can travel to the lungs, causing a life-threatening pulmonary embolism (PE).

Option A: Providing bed rest is a standard intervention, not an action to be avoided. It helps to prevent dislodging the clot and reduces swelling in the initial phase of treatment.
Option B: Elevation of the affected extremity is a recommended intervention. It uses gravity to help reduce swelling (edema) and decrease venous pressure, which alleviates pain.
Option D: Administering analgesics (pain medications) is an appropriate and necessary intervention to manage the pain and inflammation associated with DVT, improving patient comfort.

Clinical Relevance

Nursing practice connection: Use the key finding related to Nursing management and contraindications for Deep Vein Thrombosis (DVT) to guide bedside assessment, documentation, and the next nursing action.
The absolute prohibition of massaging a limb with DVT is a critical patient safety rule. Violating this can have fatal consequences.
Nurses must educate the patient and their family about not rubbing or massaging the affected leg.
A key nursing responsibility is monitoring for signs of pulmonary embolism (PE), such as sudden chest pain, shortness of breath, and tachycardia. This is a medical emergency requiring immediate intervention.

How to Approach the Question

First, identify the keyword 'avoided' in the question stem. This tells you that you are looking for a contraindicated or harmful action.
Read the diagnosis: 'deep vein thrombosis'. Recall the main danger of DVT, which is the dislodgement of the clot leading to a pulmonary embolism (PE).
Evaluate each option based on this primary danger.
Option A (Bed rest) and Option B (Elevation) are standard care measures to prevent clot movement and reduce swelling.
Option D (Analgesics) addresses the symptom of pain and is appropriate.
Option C (Massaging) involves direct physical manipulation of the area containing the clot. This action poses the highest and most direct risk of dislodging the thrombus.

Concept Tested & Keywords

Concept Tested: Nursing management and contraindications for Deep Vein Thrombosis (DVT).
Stem keywords: deep vein thrombosis, caring for a client, interventions
Lead-in keywords: avoided
Negative lead-in flag: The question asks for an intervention to be AVOIDED, which is a negative-framing keyword.

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E6 Nursing Brunner Adult Health 3SA Vol 1 Part 3 pp. 80-82, 81-83

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 2 p. 12-14

Practise the full SCTIMST Staff Nurse - 2015 (Set-A)

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