A nurse is caring for a client who has deep vein thrombosis (DVT) of their right lower leg. Which of the following manifestations should the nurse expect? (Select All that Apply.)

Warmth

Erythema

Swelling

Numbness

Bleeding

Answer and Explanation

Correct Answer : A,B,C

A. Warmth: Warmth over the affected area is a typical sign of DVT. It results from localized inflammation and increased blood flow due to the clot obstructing venous return and irritating the vessel wall.
B. Erythema: Erythema, or redness, often occurs in the area where the thrombus is located. It reflects the inflammatory response triggered by the presence of the clot in the vein.
C. Swelling: Swelling in the affected limb is one of the most common signs of DVT. It results from impaired venous return and fluid buildup due to the obstruction caused by the clot.
D. Numbness: Numbness is not typically associated with DVT. While swelling can sometimes compress nearby nerves and cause discomfort, numbness is not a hallmark feature and would warrant evaluation for other potential causes.
E. Bleeding: Bleeding is not a manifestation of DVT itself. DVT involves clot formation within a vein, not bleeding. However, anticoagulant therapy used to treat DVT can increase the risk of bleeding, but that is a side effect of treatment, not a sign of the condition.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. Obtain orders from the health care provider to discontinue catheters as soon as possible: Early removal of indwelling urinary catheters is a key strategy to prevent catheter-associated urinary tract infections (CAUTIs). Prolonged use increases the risk of bacterial colonization and infection, making prompt discontinuation essential in reducing UTI rates.
B. Encourage adequate fluid intake every day: Increased fluid intake helps flush bacteria from the urinary tract, reducing the likelihood of infection. It also promotes more frequent urination, which prevents urine stasis, a risk factor for UTIs.
C. Promote perineal care that includes wiping the perineum from the front to the back: Proper perineal hygiene helps prevent the transfer of bacteria from the rectal area to the urethra, especially in female clients, thus reducing the risk of ascending urinary tract infections.
D. Remind clients to urinate right away when they have an urge and to completely empty their bladder:
Delaying urination can lead to urinary stasis, which provides a breeding ground for bacteria. Incomplete bladder emptying also increases the risk of infection, especially in older adults with impaired bladder function.
E. Continue prescribed antibiotics even if the client's symptoms have subsided: While it is important for clients to complete a full course of antibiotics, this action is directed at treating current infections rather than preventing new ones. It is not a preventive strategy for reducing facility-wide UTI rates.

A. The client should maintain systolic BP between 141 and 145 mm Hg. B. The client should maintain systolic BP between 136 and 140 mm Hg C. The client should maintain systolic BP between 120 and 129 mm Hg. D. The client should maintain systolic BP between 130 and 135 mm Hg

Correct Answer is C

Explanation

A. The client should maintain systolic BP between 141 and 145 mm Hg. This BP range is too high for clients with hypertension, especially those who have had a transient ischemic attack (TIA). The goal is to reduce BP to lower levels to prevent further stroke risk.
B. The client should maintain systolic BP between 136 and 140 mm Hg: This is still too high. Current guidelines recommend keeping systolic BP lower to reduce the risk of recurrent strokes or further vascular damage.
C. The client should maintain systolic BP between 120 and 129 mm Hg: This is the most appropriate target for clients with hypertension and TIA. Maintaining a BP within this range is known to reduce the risk of future strokes.
D. The client should maintain systolic BP between 130 and 135 mm Hg: While this range is lower than some others, it is still above the ideal target for stroke prevention, which is under 130 mm Hg for clients at high risk.

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A nurse is caring for a client who has deep vein thrombosis (DVT) of their right lower leg. Which of the following manifestations should the nurse expect? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

A nurse manager at a skilled nursing facility has noticed an increase in urinary tract infections by 12% in the past year. In an effort to decrease this rate, which of the following should the nurse manager teach the nursing staff? (Select All that Apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is C

Explanation

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