A nurse is caring for a 75-year-old client who is admitted to the medical- surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Most Likely Condition: Deep Vein Thrombosis (DVT)
The client has multiple risk factors for developing a Deep Vein Thrombosis (DVT
•   Recent surgery: The client is 2 days postoperative following a hysterectomy, which increases the risk of blood clots.
•   Obesity: The client’s weight is 121.3 kg (267.4 lb), which significantly increases the risk of DVT
due to poor circulation and reduced mobility.
•   Physical inactivity: The client has not yet ambulated much post-surgery due to significant pain, leading to stasis of blood in the lower extremities, which can increase the risk of clots.

•   Smoking history: Smoking can damage blood vessels and increase clotting risk.
•   Noncompliance with sequential compression devices (SCDs): The client reports that SCDs "hurt too much," and as a result, they are not wearing them. SCDs are a key prevention strategy against DVT, so nonuse of them further increases the risk.

Actions to Take

Check for pedal pulses and signs of ischemia:
DVT can lead to impaired circulation and ischemia in the affected limb. The nurse should assess for pedal pulses and signs of ischemia (e.g., coldness, swelling, pallor) to evaluate the extent of blood flow to the lower extremities. Early detection of impaired circulation can prevent complications like tissue damage.
Request a prescription for a lower-extremity Doppler flow study:
A Doppler ultrasound is the gold standard for diagnosing DVT. This non-invasive test uses sound waves to assess blood flow and detect clots. It should be ordered if the nurse suspects a DVT, especially with the client’s high risk factors.

Parameters to Monitor

Signs of bleeding after anticoagulation initiation:
If the client is diagnosed with a DVT, anticoagulants (e.g., heparin, warfarin, or enoxaparin) are often prescribed to prevent the clot from growing or migrating. The nurse needs to monitor for signs of bleeding (e.g., unusual bruising, bloody stools, or hematuria) as anticoagulant therapy increases bleeding risk.
Temperature:
Fever can be an indicator of infection or inflammation. If a DVT becomes complicated by phlebitis (inflammation of the vein) or if the clot is large or causes an infection, the client may develop a fever. Regular temperature monitoring is essential for detecting early signs of infection or complications related to DVT.

Rationale for incorrect conditions;
Muscle strain: While muscle strain can occur, the client’s presentation and risk factors (recent surgery, immobility, obesity) align more with DVT. Muscle strain is usually associated with localized pain, whereas DVT often presents with swelling, pain, and redness in the lower extremity, and potentially warmth.
Cellulitis: This is an infection of the skin and underlying tissues, typically presenting with redness, swelling, and warmth. The client does not exhibit these symptoms, and there’s no indication of an infection in the notes.
Heart failure: Heart failure can cause fluid retention, which leads to swelling in the extremities, but the
client’s vital signs (e.g., normal BP, heart rate, and respiratory rate) do not suggest heart failure. Additionally, the client does not report symptoms such as shortness of breath or chest pain.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Sodium phosphate is commonly used as a bowel prep before a colonoscopy, and there is no immediate concern in this situation unless the client is showing signs of dehydration or electrolyte imbalances.
B. A positive Mantoux test induration indicates exposure to tuberculosis, which should be further evaluated, but it is not immediately urgent.
C. An increase in urinary frequency while taking bumetanide (a diuretic) is expected and should be monitored, but it is not a cause for alarm unless accompanied by other signs of dehydration or electrolyte imbalance.
D. Warfarin and breastfeeding require careful monitoring, as warfarin can pass into breast milk and affect the infant. The nurse should follow up on this situation to ensure the safety of both the mother and infant.

A. Hypotension B. Hematuria C. Weight loss D. Polyuria

Correct Answer is B

Explanation

A. Hypotension is not typically associated with acute glomerulonephritis. Instead, hypertension is more commonly seen due to fluid retention and increased vascular resistance.
B. Hematuria is a hallmark finding of acute glomerulonephritis. This condition often leads to blood in the urine, which can be seen as reddish or smoky-colored urine.
C. Weight loss is not typically associated with acute glomerulonephritis. Weight gain is more common due to fluid retention and edema caused by impaired kidney function.
D. Polyuria (excessive urination) is generally not expected in acute glomerulonephritis. Instead, oliguria (decreased urine output) is more typical, as kidney function is impaired and fluid retention occurs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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