A 50-year old female arrives to the EC with flu-like symptoms. You learn that she was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. Which assessment information will you need to communicate to the physician?
The patient says her right leg aches all night
The right calf is warm to the touch and is larger than the left calf
The patient is unable to remember her husband's name
There are multiple ecchymotic areas on the patient's arms
The Correct Answer is B
Rationale:
A. The patient says her right leg aches all night is incorrect. While pain is an important subjective symptom, it is less specific than objective signs. The physician will want concrete findings that indicate possible recurrent or worsening DVT, not just general discomfort.
B. The right calf is warm to the touch and is larger than the left calf is correct. These are classic objective signs of deep vein thrombosis (DVT), which is especially concerning given her recent history of DVT and pulmonary embolism. Calf swelling, warmth, and asymmetry indicate possible thrombus progression or recurrence, which is a medical emergency that requires immediate physician notification for anticoagulation or further imaging.
C. The patient is unable to remember her husband's name is incorrect in this context. Memory loss may indicate cognitive impairment, delirium, or infection, but it is not directly related to her recent thromboembolic history. While important to document, it is not the most urgent finding to communicate regarding DVT risk.
D. There are multiple ecchymotic areas on the patient's arms is incorrect. Ecchymosis may suggest bruising from trauma, anticoagulation, or bleeding disorders, but in isolation it does not indicate an acute thromboembolic event. While noteworthy, the priority concern in this patient is signs of recurrent DVT, given her history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Stable vital signs and ABGs is correct. Successful weaning from mechanical ventilation depends on the patient’s ability to maintain adequate gas exchange and hemodynamic stability. Stable vital signs (heart rate, blood pressure, respiratory rate) indicate cardiovascular stability, and normal arterial blood gases (ABGs) demonstrate that the patient can maintain sufficient oxygenation (PaO₂) and ventilation (PaCO₂) without assistance. These are the most reliable physiological predictors of successful weaning.
B. Pulse oximetry above 80% and stable vital signs is incorrect because a PaO₂ corresponding to an SpO₂ of 80% indicates significant hypoxemia. Successful weaning generally requires adequate oxygenation (SpO₂ typically ≥90% on minimal oxygen support) to ensure tissue oxygen delivery. Stable vital signs alone are not sufficient if oxygenation is inadequate.
C. Stable nutritional status and ABGs is incorrect because while good nutrition supports overall recovery and respiratory muscle strength, it is not an immediate predictor for weaning readiness. ABGs are important, but nutritional status alone does not determine ventilator independence.
D. Normal orientation and level of consciousness is incorrect because cognitive status is supportive but not the primary determinant of weaning success. Patients can be sedated or temporarily altered in consciousness and still be physiologically ready if vital signs and ABGs are stable. Cognitive ability mainly affects cooperation during weaning trials rather than physiological readiness.
Correct Answer is B
Explanation
Rationale:
A. Connecting IV fluids is a routine step in central line management, but it does not help detect procedural complications. While necessary for therapy, it does not identify immediate life-threatening risks.
B. The most serious complication of subclavian central line insertion is pneumothorax, which occurs if the needle or catheter punctures the lung. Pneumothorax can lead to respiratory distress or tension pneumothorax if untreated. Listening to bilateral breath sounds immediately after the procedure helps the nurse detect absent or diminished breath sounds on the affected side, which may indicate a pneumothorax requiring urgent intervention.
C. Checking fluid compatibility is important for safe medication administration, but it is not related to detecting procedural complications such as pneumothorax, air embolism, or bleeding.
D. Applying a sterile dressing protects the insertion site from infection and maintains catheter stability, but it does not detect acute, life-threatening complications from line placement.
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