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Select all the factors regarding a deep vein thrombosis that are included in Virchow's Triad:
- A. Hypocoagulability
- B. Atherosclerosis
- C. Endothelial damage
- D. Stasis of venous blood
- E. Excessive coagulability
- F. Increased venous blood flow
Correct Answer: C,D,E
Rationale: Virchow's Triad details the THREE factors (hence why it called a triad) for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage.
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Which discharge instruction is most appropriate for reducing the client's fatigue and shortness of breath during mealtimes?
- A. Eat simple carbohydrates for quick energy.
- B. Eat fatty foods to get maximum caloric intake.
- C. Eat frequent, small meals to reduce energy use.
- D. Eat the largest meal late at night before sleep.
Correct Answer: C
Rationale: Frequent, small meals reduce the energy required for digestion, minimizing fatigue and shortness of breath in COPD clients.
Which nursing action is most appropriate immediately after the chest tube is removed from the client?
- A. Apply a sterile dressing and tape it securely.
- B. Request a chest X-ray to assess lung fields.
- C. Administer oxygen by nasal cannula.
- D. Encourage the client to cough vigorously.
Correct Answer: A
Rationale: Applying a sterile dressing taped securely prevents air entry into the pleural space and promotes healing post-chest tube removal.
Which diagnostic test should the nurse anticipate the health-care provider ordering to rule out the diagnosis of asthma in clients diagnosed with chronic obstructive pulmonary disease (COPD)?
- A. A bronchoscopy.
- B. An immunoglobulin E.
- C. An arterial blood gas.
- D. A bronchodilator reversibility test.
Correct Answer: D
Rationale: A bronchodilator reversibility test differentiates asthma from COPD by assessing whether airway obstruction is reversible. In asthma, lung function (e.g., FEV1) improves significantly post-bronchodilator, while COPD shows minimal improvement. Bronchoscopy (A) is invasive and not specific for this differentiation. Immunoglobulin E (B) is relevant for allergies, not distinguishing asthma from COPD. Arterial blood gases (C) assess oxygenation but do not differentiate these conditions.
A patient is presenting with chronic obstructive pulmonary disease. The patient has a chronic productive cough with dyspnea on excretion. Arterial blood gases show a low oxygen level and high carbon dioxide level in the blood. On assessment, the patient has cyanosis in the lips and edema in the abdomen and legs. Based on your nursing knowledge and the patient's symptoms, you suspect the patient suffers from what type of COPD?
- A. Emphysema
- B. Pneumonia
- C. Chronic bronchitis
- D. Pneumothorax
Correct Answer: C
Rationale: Chronic bronchitis , a type of COPD, is characterized by chronic productive cough, hypoxemia, hypercapnia, cyanosis, and edema from right heart failure. Emphysema typically shows barrel chest, pneumonia is an infection, and pneumothorax involves lung collapse.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical unit. Which information provided by the UAP warrants immediate intervention by the nurse?
- A. The client diagnosed with cancer of the lung has a small amount of blood in the sputum collection cup.
- B. The client diagnosed with chronic emphysema is sitting on the side of the bed and leaning over the bedside table.
- C. The client receiving Procrit, a biologic response modifier, has a T 99.2°F, P 68, R 24, and BP of 198/102.
- D. The client receiving prednisone, a steroid, is complaining of an upset stomach after eating breakfast.
Correct Answer: C
Rationale: Hypertension (198/102) with Procrit (C) suggests a serious side effect, requiring immediate intervention. Hemoptysis (A), tripod position (B), and stomach upset (D) are expected or less urgent.