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.

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Correct Answer is B

Explanation

A. Penicillin G is not related to sulfa drugs, so checking for a sulfa allergy is not necessary. The nurse should, however, assess for penicillin allergies.
B. Diarrhea can indicate an adverse reaction such as antibiotic-associated colitis (e.g., Clostridium difficile infection), so the client should be instructed to report this symptom.
C. Penicillin G is typically infused over 30 to 60 minutes, not 10 minutes. Infusing it too quickly could increase the risk of side effects.
D. Penicillin G should be stored according to the manufacturer's instructions, but refrigeration is not always necessary. The nurse should check the specific instructions.

A. Review the need for the indwelling urinary catheter daily. B. Encourage the client to drink 3000 mL of fluid daily. C. Place the drainage bag on the bed when transporting the client. D. Empty the drainage bag when it is half-full. E. Change the indwelling urinary catheter tubing every 3 days. F. Use soap and water to provide perineal care.

Correct Answer is ["A","B","F"]

Explanation

Rationale
A. Review the need for the indwelling urinary catheter daily.
One of the most effective strategies to prevent UTIs is avoiding unnecessary catheterization. The nurse should regularly assess whether the catheter is still necessary and remove it as soon as possible. Keeping a catheter in place longer than needed increases the risk of infection.
B. Encourage the client to drink 3000 mL of fluid daily.
Increasing fluid intake is generally a good measure to help flush the urinary tract, reducing the concentration of bacteria and preventing infections. However, for clients with heart failure, excessive fluid intake can exacerbate fluid overload, leading to pulmonary edema and worsened symptoms of heart failure. Therefore, the nurse should consult the healthcare provider before recommending a specific amount of fluid intake (such as 3000 mL). The nurse should ensure that the client’s fluid intake is balanced with their heart failure management plan.
C. Place the drainage bag on the bed when transporting the client.
The drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which can lead to infections. Placing the drainage bag on the bed when transporting the client would increase the risk of urine reflux, potentially leading to a UTI. The bag should be secured properly and kept off the bed or floor during transport.
D. Empty the drainage bag when it is half-full.
The drainage bag should be emptied when it is full (typically around 2/3 to 3/4 full) to prevent overfilling, which can increase the risk of backflow or spillage. Emptying the bag when it is half-full may lead to unnecessary handling of the catheter and increases the risk of contamination. It’s important to empty the bag regularly, but not excessively often.
E. Change the indwelling urinary catheter tubing every 3 days.
There is no need to change the indwelling catheter tubing on a regular basis unless there is a specific indication (e.g., blockage or infection). Frequent changes of the catheter tubing increase the risk of introducing bacteria. According to best practice guidelines, the catheter should be changed only when necessary, not routinely every 3 days.
F. Use soap and water to provide perineal care.
Regular and gentle perineal care with soap and water is crucial for reducing the risk of UTIs. The perineal area should be cleaned daily and after any incontinence episodes to minimize bacterial contamination of the catheter and urinary tract. It’s important to avoid harsh chemicals, which could irritate the skin and urinary tract.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client in the medical-surgical unit. Exhibits Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

Correct Answer is ["A","B","F"]

Explanation

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