Question

A client with deep vein thrombosis (DVT) in the left leg is on heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

a. Encourage mobilization to prevent pulmonary embolism
b. Assess blood pressure and heart rate at least every four hours
c. Observe for bleeding side effects related to heparin therapy
d. Measure each calf's girth to evaluate edema in the affected leg

Answer 1

The most important intervention for a client with deep vein thrombosis (DVT) on a heparin protocol is to encourage mobilization to prevent pulmonary embolism (PE). This helps in preventing blood from pooling in the legs and reduces the risk of clot formation.

Step-by-step explanation:

The most important intervention for the nurse to include in a client's plan of care who has deep vein thrombosis (DVT) and is on a heparin protocol is to encourage mobilization to prevent pulmonary embolism (PE).

PE is a serious complication of DVT where the blood clot breaks off and travels to the lungs, which can be life-threatening. Mobilizing the client helps in preventing blood from pooling in the legs and reduces the risk of clot formation.

Assessing blood pressure and heart rate, observing for bleeding side effects related to heparin therapy, and measuring calf's girth to evaluate edema in the affected leg are important interventions, but they are not as critical as encouraging mobilization to prevent PE.