A client presents with swelling, redness, and warmth in one leg. The nurse suspects deep vein thrombosis (DVT). What initial assessment should the nurse perform to confirm the presence of DVT?
Auscultating the lungs for crackles.
Checking for a positive Homans' sign.
Measuring blood pressure in both arms.
Performing a capillary refill test.
The Correct Answer is B
A) This choice is incorrect because auscultating the lungs for crackles is not directly related to confirming the presence of deep vein thrombosis (DVT). Lung auscultation may be performed to assess for potential complications of DVT, such as pulmonary embolism.
B) This choice is correct. Homans' sign is a clinical test used to assess for the presence of DVT. The nurse flexes the client's knee and gently dorsiflexes the foot. A positive Homans' sign is indicated by calf pain or discomfort during dorsiflexion and may suggest the presence of a blood clot in the deep veins of the leg.
C) This choice is incorrect because measuring blood pressure in both arms is not a specific assessment for deep vein thrombosis (DVT). It may be done as part of a routine assessment but does not confirm the presence of DVT.
D) This choice is incorrect because performing a capillary refill test is not specific to DVT assessment. Capillary refill is a measure of peripheral perfusion and may be useful in assessing overall circulatory status, but it does not directly confirm the presence of DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) This choice is correct. Gender is a non-modifiable risk factor for DVT, with women generally having a higher risk than men. Hormonal changes, such as those associated with pregnancy, oral contraceptives, and hormone replacement therapy, can contribute to the increased risk in women.
B) This choice is incorrect because obesity is a modifiable risk factor for DVT, not a non-modifiable one. Clients can work to achieve and maintain a healthy weight to reduce their risk.
C) This choice is incorrect because smoking history is a modifiable risk factor for DVT. Clients can quit smoking to decrease their risk of blood clot formation.
D) This choice is incorrect because a sedentary lifestyle is a modifiable risk factor for DVT. Clients can engage in regular physical activity to reduce their risk.
Correct Answer is A
Explanation
A) This choice is correct. Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver. Consistent vitamin K intake can impact the effectiveness of warfarin, so it is important for clients to maintain a stable vitamin K intake and avoid sudden changes in their diet.
B) This choice is incorrect because warfarin does not directly dissolve the blood clot in the leg. It prevents the formation of new clots and allows the body's natural mechanisms to dissolve the existing clot over time.
C) This choice is incorrect because while taking warfarin at the same time each day can help with adherence, the priority teaching point is about vitamin K intake and not the exact timing of the medication.
D) This choice is incorrect because discontinuing warfarin without medical guidance can be dangerous. Warfarin is typically prescribed for a specific duration, and its cessation should be guided by the healthcare provider based on the client's individual condition and risk factors.
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