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

When a patient is informed about a serious diagnosis like breast cancer and the need for a mastectomy, it is common for them to experience a range of emotions, including sadness, fear, and anxiety. As a nurse, providing emotional support and creating a safe space for the patient to express their feelings is crucial. Offering to be there for the patient if they want to talk acknowledges their emotional distress and provides comfort.

Choice B rationale

Asking the patient why they are upset may come across as insensitive or dismissive. The patient has just received a life-changing diagnosis, and their emotional reaction is completely normal and expected. It’s important to provide support and empathy rather than questioning their feelings.

Choice C rationale

Telling the patient that everything will be alright and there is no need to cry may seem comforting, but it can actually invalidate the patient’s feelings. It’s important to acknowledge the patient’s emotions and allow them to express their feelings without judgment.

Choice D rationale

Telling the patient that they will recover may be seen as providing false reassurance. While it’s important to maintain hope, it’s also crucial to be honest and realistic with the patient about their diagnosis and treatment.

A. Administer morphine 2-4 mg IV prn for pain. B. Apply a figure of 8 pressure dressing starting day two post-operatively. C. Administer antibiotics as prescribed. D. Apply ice to the stump for 60-90 minutes.

Correct Answer is A

Explanation

The correct answer is Choice A. After a below-the-knee amputation (BKA), pain management is crucial. Administering morphine 2-4 mg IV prn for pain is an appropriate physician’s order to implement. Pain can be severe after amputation, and effective pain management can improve patient comfort, reduce anxiety, and aid in recovery. Applying a figure of 8 pressure dressing starting day two post-operatively (Choice B) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact. Administering antibiotics as prescribed (Choice C) is important, but it is not the first action to take. Pain management is the priority immediately after surgery. Applying ice to the stump for 60-90 minutes (Choice D) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.

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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 physician has just informed a patient that they have breast cancer and will require a mastectomy. The nurse finds that the patient is crying. Which response by the nurse is most appropriate?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A client with diabetes has returned from the post-anesthesia care unit (PACU) after a below-the-knee amputation (BKA) of the left leg. Which physician’s order should the nurse implement?

Correct Answer is A

Explanation

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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?