Nokea
The nurse is assessing a patient, who has many risk factors for the development of a DVT, for signs and symptoms of a deep vein thrombosis. What signs and symptoms below would possibly indicate a deep vein thrombosis is present?
- A. Cool extremity
- B. Decreases pulses
- C. Redness
- D. Pain
- E. Warm extremity
- F. Swelling
- G. Cyanosis
Correct Answer: C,D,E,F
Rationale: Signs and symptoms of a DVT include: redness, swelling, warm extremity, pain, positive Homan's Sign, and swelling (which can be unilateral...meaning there is more swelling in one extremity compared to the other).
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Which statement below is incorrect about a deep vein thrombosis (DVT)?
- A. Veins that are most susceptible to a deep vein thrombosis are the peroneal, posterior tibial, popliteal and superficial femoral.
- B. DVTs tend to mostly occur in the lower extremities but can occur in the upper extremities too.
- C. A deep vein thrombosis in the lower extremity has a low probability of becoming a pulmonary embolism.
- D. A DVT is a type of venous thromboembolism (VTE), which is a blood clot that starts in the vein.
Correct Answer: C
Rationale: This option is INCORRECT. All the other statements are true about a DVT. Option C is wrong because it should say: 'A deep vein thrombosis in the lower extremity has a HIGH (not low) probability of becoming a pulmonary embolism.'
Which of the following signs and symptoms would indicate that the client is experiencing oxygen toxicity? Select all that apply.
- A. Nonproductive cough
- B. Nausea
- C. Restlessness
- D. Headache
- E. Substernal chest pain
- F. Nasal stuffiness
Correct Answer: A, D, E
Rationale: Oxygen toxicity from prolonged high-concentration oxygen can cause a nonproductive cough, headache, and substernal chest pain.
A patient taking Isoniazid (INH) should be monitored for what deficiency?
- A. Vitamin C
- B. Calcium
- C. Vitamin B6
- D. Potassium
Correct Answer: C
Rationale: Isoniazid can cause peripheral neuropathy due to vitamin B6 (pyridoxine) deficiency. Patients are often given B6 supplements and monitored for this deficiency.
The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering?
- A. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9.
- B. Multiple Choice insulin to a client with a blood glucose level of 218 mg/dL.
- C. Hang the heparin bag on a client with a PT/PTT of 12.9/98.
- D. A calcium channel blocker to the client with a BP of 112/82.
Correct Answer: C
Rationale: PTT 98 (C) is supratherapeutic for heparin, risking bleeding, so question administration. INR 1.9 (A) is subtherapeutic, insulin (B) is appropriate, and CCB (D) is reasonable.
Which nursing action is essential during tracheal suctioning?
- A. Using a lubricant such as petroleum jelly
- B. Administering 100% oxygen before and after suctioning
- C. Making sure the suction catheter is open or on during insertion
- D. Assisting the client to assume a supine position during suctioning
Correct Answer: B
Rationale: Administering 100% oxygen before and after suctioning prevents hypoxia during the procedure.