A nurse recently hired to the preoperative area learns that certain patients are at higher risk for venous thromboembolism (VTE). Which patients are considered to be at high risk? (Select all that apply.)

Morbidly obese patient

A woman who smokes and takes oral contraceptives or smoke

Wheelchair-bound patient

Patient with a humerus fracture

Patient who underwent a prolonged surgical procedure

Answer and Explanation

Correct Answer : A,B,E

A. Morbidly obese patient: Obesity is a known risk factor for VTE due to several reasons. Morbidly obese individuals often have impaired mobility, which can lead to venous stasis (sluggish blood flow in the veins). Additionally, obesity is associated with inflammation and changes in blood clotting factors, increasing the risk of developing blood clots in the veins.

B. A woman who smokes and takes oral contraceptives or smokes: Both smoking and oral contraceptive use are independent risk factors for VTE. Smoking can cause damage to blood vessels and alter blood clotting mechanisms, while oral contraceptives can increase the risk of blood clots due to hormonal changes.

C. Wheelchair-bound patient: While being wheelchair-bound alone may not always indicate a high risk for VTE, immobility is a significant risk factor for developing blood clots. Prolonged periods of immobility can lead to blood stasis in the veins, making wheelchair-bound patients susceptible to VTE, especially if other risk factors are present.

D. Patient with a humerus fracture: A humerus fracture on its own may not necessarily increase the risk of VTE significantly. However, if the fracture requires immobilization or surgery, especially if it affects the lower extremities or leads to prolonged immobility, the risk of VTE can increase due to decreased blood flow and stasis.

E. Patient who underwent a prolonged surgical procedure: Prolonged surgical procedures often involve anesthesia, immobility during surgery, and postoperative immobilization, all of which can contribute to venous stasis and increase the risk of developing VTE. Additionally, the surgical trauma itself can trigger inflammatory responses and alterations in blood clotting factors, further elevating the risk of blood clots.

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Correct Answer is ["B","C","E"]

Explanation

A. Healthy middle-aged adult who never had chickenpox:

This individual has not had chickenpox, which means they are susceptible to varicella-zoster virus (VZV) infection. If they contract herpes zoster (shingles), they are at risk for complications, although typically healthy adults are less likely to experience severe complications compared to immunocompromised individuals or older adults.

B. Older adult who takes large doses of prednisone for a chronic condition:

Chronic corticosteroid use, such as prednisone, can suppress the immune system and increase the risk of herpes zoster infection. Additionally, if herpes zoster develops in an older adult, they are at higher risk for complications such as postherpetic neuralgia (persistent nerve pain), bacterial superinfection of the rash, and dissemination of the virus.

C. Middle-aged adult who just started taking chemotherapy:

Chemotherapy suppresses the immune system, making individuals more susceptible to infections. If a person undergoing chemotherapy develops herpes zoster, they are at increased risk for serious complications due to their weakened immune response.

D. Nurse who recently received the first dose of varicella vaccine:

The varicella vaccine is designed to prevent chickenpox and reduce the risk of herpes zoster (shingles) in vaccinated individuals. Therefore, a nurse who received the varicella vaccine is less likely to experience serious complications from herpes zoster infection compared to those who are unvaccinated.

E. Young adult who is positive for the human immunodeficiency virus (HIV):

Individuals with HIV have a weakened immune system, increasing their susceptibility to infections, including herpes zoster. Moreover, herpes zoster in HIV-positive individuals can be more severe, prolonged, and may lead to complications such as disseminated herpes zoster, involving multiple organs and potentially becoming life-threatening.

A. increase the effectiveness of the skin graft. B. promote movement in the affected area. C. prevent infection and promote healing. D. promote suppuration of the wound.

Correct Answer is C

Explanation

A. Increase the effectiveness of the skin graft:

Debridement can indeed increase the effectiveness of a skin graft by preparing a clean, viable wound bed for grafting. Removing dead tissue and debris helps the skin graft adhere to healthy tissue and promotes successful graft take. However, this is not the primary purpose of debridement.

B. Promote movement in the affected area:

While debridement can indirectly contribute to promoting movement by improving wound healing and reducing pain, the primary purpose of debridement is not to promote movement in the affected area.

C. Prevent infection and promote healing:

This statement accurately reflects the primary purpose of debridement. By removing nonviable tissue, debris, and foreign material from the wound, debridement helps prevent infection by reducing the bacterial load and creating an environment conducive to healing. It also promotes granulation tissue formation and wound contraction, which are essential for wound healing.

D. Promote suppuration of the wound:

Suppuration refers to the formation and discharge of pus from a wound, often indicating infection. Debridement aims to remove necrotic tissue and prevent infection, so promoting suppuration is not a desired outcome of debridement.

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A nurse recently hired to the preoperative area learns that certain patients are at higher risk for venous thromboembolism (VTE). Which patients are considered to be at high risk? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which people have the greatest risk for serious complications secondary to herpes zoster infection? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

The nurse debriding a burn wound explains that the purpose of debridement is to:

Correct Answer is C

Explanation

Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from:

A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?

A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?

A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?

A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? (Select all that apply.)

A nurse is giving a preoperative patient a dose of famotidine ( Pepcid). The patient asks why the nurse is giving this drug when the patient has no history of ulcers. What response by the nurse is best?

A nurse is reviewing the client's medical record in the presurgical holding area. Which of the following places the client at risk for a surgical site infection?