A 38-year-old female client was diagnosed with a right lower extremity deep vein thrombosis (DVT) after surgery 2 days ago. This morning the nurse reviews the client's electronic health record to complete a shift assessment. Data from the health record include a prescription from the primary health care provider for warfarin 5 mg orally every day, and the following laboratory results:

Hemoglobin: 17 g/dL

Hematocrit: 44.9%

WBC count: 5500/mm³

Platelets: 160,000/mm³

aPTT: 40 sec

PT: 12 sec

INR: 0.9

BUN: 16 mg/dL

Creatinine: 0.6 mg/dL

The nurse assesses the client for which signs and symptoms of a DVT?

Unilateral edema

Nausea

Groin discomfort

Calf pain

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: Unilateral edema is a common sign of DVT. This occurs due to the obstruction of blood flow in the affected vein, leading to fluid buildup in the tissue, which causes swelling. The swelling is usually confined to the area of the leg where the clot is located, making it an important diagnostic indicator. In DVT, the affected limb often appears swollen compared to the other limb, and this can be easily observed by the healthcare provider during the physical examination.

Choice B reason: Nausea is not typically associated with DVT. While nausea can occur due to various medical conditions, it is not a primary symptom of DVT. DVT primarily affects the circulatory system, leading to symptoms related to impaired blood flow, such as swelling, pain, and redness in the affected limb. Therefore, nausea is unlikely to be directly related to the presence of a blood clot in the deep veins of the leg.

Choice C reason: Groin discomfort can be a symptom of DVT, especially if the clot is located in the femoral vein. The femoral vein runs through the groin area, and a clot in this vein can cause pain and tenderness in the groin. This discomfort is due to the pressure and inflammation caused by the clot obstructing blood flow. Patients may report a dull or aching pain in the groin, which can be exacerbated by movement or pressure.

Choice D reason: Calf pain is a classic symptom of DVT. It often presents as cramping, soreness, or aching in the calf due to the presence of a blood clot in the deep veins of the leg. The pain is caused by the increased pressure and inflammation in the affected vein, which irritates the surrounding tissues. This symptom is a key indicator of DVT and should prompt further evaluation and diagnostic testing, such as an ultrasound, to confirm the presence of a clot.

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Correct Answer is ["133"]

Explanation

Step 1: First, we need to determine how many mL per hour the IV is administering. We know that 100 mL is administered over 45 minutes.

Step 2: Convert 45 minutes to hours. 45 minutes ÷ 60 minutes = 0.75 hours

Step 3: Calculate the flow rate in mL per hour. 100 mL ÷ 0.75 hours

Step 4: Perform the division. 100 ÷ 0.75 = 133.33

Step 5: Round to the nearest whole number. 133.33 rounds to 133.

Answer: The flow rate is 133 mL per hour.

A. Assess for unilateral swelling, redness, and tenderness of either leg. B. Ask about any skin color changes that occur in response to cold. C. Palpate for the presence of dorsalis pedis and posterior tibial pulses. D. Look for the presence of tortuous veins bilaterally on the legs.

Correct Answer is C

Explanation

Choice A reason: Assessing for unilateral swelling, redness, and tenderness is important when evaluating for conditions such as deep vein thrombosis (DVT). However, this patient's symptoms of leg cramps and pain that subsides with rest are more indicative of peripheral artery disease (PAD) rather than DVT. Therefore, while this assessment is valuable in certain contexts, it is not the most relevant for this patient's symptoms.
Choice B reason: Asking about skin color changes that occur in response to cold can help identify conditions such as Raynaud's phenomenon, which causes extremities to change color in response to cold or stress. However, this patient's symptoms of intermittent leg cramps and pain with walking are more suggestive of PAD, making this question less relevant in this situation.
Choice C reason: Palpating for the presence of dorsalis pedis and posterior tibial pulses is the most appropriate focused assessment. This patient's symptoms of leg cramps and pain that resolve with rest suggest intermittent claudication, which is a hallmark of PAD. By palpating these pulses, the nurse can assess the adequacy of blood flow to the lower extremities, which is crucial in diagnosing PAD.
Choice D reason: Looking for the presence of tortuous veins bilaterally on the legs is important for identifying varicose veins, which are characterized by enlarged, twisted veins. While varicose veins can cause leg discomfort, they are not typically associated with the type of pain that subsides with rest. This patient's symptoms are more indicative of PAD, making this assessment less relevant.

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Naxlex Comprehensive Predictor Exams

Determine the flow rate in mL per hour for the following IV being administered by infusion pump: Ampicillin 1.5g in 100 mL 0.9% NS over 45 minutes: Round to the whole number.

Correct Answer is ["133"]

Explanation

A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." Which focused assessment would the nurse make?

Correct Answer is C

Explanation

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