The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?

Have client use the incentive spirometer every hour

Help client dangle legs off the side of the bed

Encourage the client to ambulate as soon as possible

Keep the client in bed with knees elevated

Limit the amount of fluid the client drinks

Answer and Explanation

The Correct Answer is B

A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.

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Correct Answer is C

Explanation

A. Poor hair growth is more associated with arterial insufficiency.
B. A weak pulse may suggest arterial, not venous, insufficiency.
C. Edema is a common finding in venous insufficiency due to fluid pooling in the extremities.
D. Muscle atrophy is not typically associated with venous insufficiency.
E. Pale color is more indicative of arterial insufficiency, while venous insufficiency may present with darkened or reddish skin.

A. Can be caused by a poorly compliant (stiff) ventricle B. Can occur with congestive heart failure C. Heard just after S1 D. Always pathologic E. An expected finding in adolescents

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

Explanation

A. An S3 is often associated with a stiff or poorly compliant ventricle.
B. An S3 heart sound can be an indication of congestive heart failure in adults, as it reflects increased fluid volume and pressure in the ventricles.
C. S3 is heard just after S2, not S1.
D. The S3 heart sound is not always pathologic. It is often benign in children, adolescents, and young adults, where it may occur due to a rapid filling phase of the ventricles.
E. In adolescents and younger individuals, an S3 heart sound is usually considered a normal finding.

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The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with a venous insufficiency of the right leg. What assessment findings does the nurse expect to find with this condition?

Correct Answer is C

Explanation

When performing a cardiovascular assessment, what would the nurse understand about an S3 heart sound? Select all that apply

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

Explanation

When assessing tactile fremitus, increased tactile fremitus is expected under which condition?

The RN and certified nursing assistant/patient care assistance (CNA/PCA) are caring for five clients on a medical/surgical unit. Which of the following tasks would be most appropriate for the nurse to delegate to the CNA/PCA?

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The nurse is asked to describe what the heart sound S2 represents. What would be the correct response by the nurse?

A client has been diagnosed with peripheral arterial insufficiency to the right leg. Which of these findings would the nurse expect to find with this condition?

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