A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative.

Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

Cataract extraction.

Myringotomy.

Laparoscopic appendectomy.

Hip arthroplasty.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Cataract extraction is a minor procedure and does not pose a significant risk for DVT.
Choice B rationale:
Myringotomy, a procedure to drain fluid from the middle ear, also does not significantly increase DVT risk.
Choice C rationale:
Laparoscopic appendectomy, while more invasive, still carries a lower DVT risk compared to major orthopedic surgeries.
Choice D rationale:
Hip arthroplasty, a major orthopedic surgery, poses a high risk for DVT due to prolonged immobility and venous stasis.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is []

Explanation

Condition Most Likely Experiencing:

Delirium

Explanation: The client has acute confusion, disorganized thinking, restlessness, incoherent speech, and altered sleep-wake cycle—all classic signs of delirium. The sudden onset (starting the previous evening) and fever (38.6°C) suggest a potential underlying cause, such as infection or dehydration.

Actions to Take:

Monitor the client's fluid intake and output.

Explanation: The client has severe fluid imbalance (250 mL intake vs. 2,500 mL output), leading to dehydration, which can contribute to delirium. Monitoring intake and output is critical for managing hydration status.

Encourage family members to stay with the client.

Explanation: Familiar faces can help reorient the client and reduce agitation. Delirium often improves with familiar environmental cues and reassurance.

Parameters to Monitor:

Sleep-wake cycle.

Explanation: Disrupted sleep patterns are a key symptom of delirium. Tracking sleep can help assess improvement or worsening of the condition.

Fall risk.

Explanation: The client is attempting to get out of bed without assistance, which puts them at high risk for falls. Close monitoring is essential to prevent injury.

Incorrect Choices and Explanations:

Request a prescription for benzodiazepine.

Why Incorrect? Benzodiazepines can worsen delirium, especially in older adults, by increasing confusion and fall risk.

Assist the client to identify coping skills.

Why Incorrect? Delirium is an acute medical condition, not a psychological disorder. The focus should be on treating the underlying cause, not psychological coping strategies.

Encourage the client to exercise.

Why Incorrect? The client is confused, weak, and at risk of falls. Exercise is not appropriate at this stage.

BUN level.

Why Incorrect? While kidney function (BUN) could be affected by dehydration, monitoring fluid balance directly (intake/output) is more immediate and relevant.

Weight loss.

Why Incorrect? While the client has refused to eat or drink, weight loss occurs over time, whereas the primary concern is acute dehydration and delirium.

Suicidal ideation.

Why Incorrect? There is no indication of suicidal thoughts. The confusion and agitation are more likely due to delirium than depression.

A. Airway obstruction. B. Paralytic ileus. C. Infection. D. Fluid imbalance.

Correct Answer is A

Explanation

Choice A rationale:
Airway obstruction is the immediate life-threatening risk due to swelling and blistering in the airway.
Choice B rationale:
Paralytic ileus is a potential complication, but it is not the immediate priority.
Choice C rationale:
Infection is a risk due to loss of skin integrity, but it is not the immediate priority.
Choice D rationale:
Fluid imbalance is a risk due to fluid loss from the burns, but airway management is the immediate priority.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Incorrect Choices and Explanations:

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is A

Explanation

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include?

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?.

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative.

Which of the following surgical procedures places the client at risk for deep-vein thrombosis?