The nurse is caring for the following four clients on the nursing unit.
Which client is at the highest risk for the development of deep vein thrombosis?

55-year-old man with a past medical history of a myocardial infarction.

45-year-old woman post laparoscopic knee replacement.

65-year-old woman post major open abdominal surgery.

50-year-old man with a peptic ulcer.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While a past medical history of myocardial infarction does increase the risk of deep vein thrombosis (DVT), it is not the highest risk factor among the options provided. Other factors such as immobility, surgery, and certain medical conditions can pose a higher risk.

Choice B rationale

Postoperative patients, such as those who have had a laparoscopic knee replacement, are at an increased risk for DVT due to periods of immobility and changes in blood flow and clotting.

However, the risk is not as high as in patients who have undergone major open abdominal surgery.

Choice C rationale

Patients who have undergone major open abdominal surgery are at the highest risk for the development of DVT among the options provided. The surgery itself, along with the postoperative period of immobility, significantly increases the risk of DVT34567.

Choice D rationale

While peptic ulcers can be associated with certain risk factors for DVT, such as age and immobility due to pain, they do not pose as high a risk as major open abdominal surgery.

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Correct Answer is A

Explanation

Choice A rationale

A decrease in inflammation at the site of infection is a key indicator that antibiotic therapy is effective. Inflammation is a response to infection, so if the inflammation is reducing, it suggests that the infection is being successfully treated.

Choice B rationale

An increase in circulating neutrophils could indicate an ongoing response to infection, rather than resolution. Neutrophils are a type of white blood cell that the body produces more of when there’s an infection. Therefore, an increase in neutrophils does not necessarily indicate that the antibiotic therapy has been effective.

Choice C rationale

A positive culture and sensitivity report indicates the presence of bacteria and identifies which antibiotics the bacteria are sensitive to. While this information is crucial for selecting the most effective antibiotic, it does not indicate whether the chosen antibiotic therapy has been effective.

Choice D rationale

A symptomatic fever could indicate an ongoing infection, rather than resolution. While fever can decrease as an infection is brought under control, the presence of a symptomatic fever does not necessarily indicate that the antibiotic therapy has been effective.

A. Trendelenburg with the stump supported on three pillows. B. Side lying with amputated leg flexed. C. Prone for 24 hours. D. Supine with the stump flat on the bed.

Correct Answer is D

Explanation

Choice A rationale

The Trendelenburg position, with the stump supported on three pillows, is not typically recommended following a below-the-knee amputation. This position could increase the risk of contractures.

Choice B rationale

Side lying with the amputated leg flexed is not typically recommended following a below-the- knee amputation. This position could increase the risk of contractures.

Choice C rationale

Lying prone for 24 hours is not typically recommended following a below-the-knee amputation. While some prone positioning may be beneficial to prevent hip flexion contractures, it should not be the only position used.

Choice D rationale

The supine position, with the stump flat on the bed, is often recommended following a below- the-knee amputation. This position helps to prevent contractures and promotes healing.

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The nurse is caring for the following four clients on the nursing unit. Which client is at the highest risk for the development of deep vein thrombosis?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating the patient’s response to antibiotic therapy. Which data would indicate that the medication has been effective?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is caring for a client who has just returned to the nursing unit following a below-the-knee amputation (BKA) of the right leg. How should this client be positioned?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Which prescribed medication for the client recovering from a traumatic amputation does the nurse correlate to the treatment of phantom limb pain?

The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis. What is the priority nursing action?

The client, on an intensified insulin regimen, consistently has a fasting blood glucose between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. What is the nurse’s interpretation of these findings?

The nurse is teaching a patient to wash their hands after using the bathroom as an attempt to break the chain of infection. Between which two links in the chain of infection does this action intervene?

A patient diagnosed with deep vein thrombosis asks the nurse, “How does this blood thinner heparin work?” Which response is most accurate?

A patient diagnosed with Type 1 diabetes reports a blood glucose level of 210 mg/dL and symptoms of a sore throat, cough, and fever. What advice should the nurse give to the patient?

To prevent lipodystrophy in a client receiving insulin therapy, what should the nurse instruct the client to do?

The nurse is monitoring a client receiving gentamicin. Which of the following would the nurse assess as potential toxic effects of this medication?

The nurse is caring for the following four clients on the nursing unit.
Which client is at the highest risk for the development of deep vein thrombosis?