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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) This choice is incorrect because DVT is not caused by a bacterial infection in the blood vessels. It is primarily related to the formation of blood clots within the veins due to various risk factors.

B) This choice is incorrect because while injuries may be associated with DVT in some cases, they are not the primary cause. The formation of blood clots in the veins remains the underlying cause.

C) This choice is incorrect because atherosclerosis in the arteries is not the main cause of DVT. Atherosclerosis is a condition that involves the buildup of plaque in the arteries, not the veins.

D) This choice is correct. Deep vein thrombosis (DVT) is primarily caused by the formation of blood clots within the veins, typically in the lower extremities. These clots can obstruct blood flow and may lead to serious complications if not treated promptly.

A. Mild leg swelling after prolonged standing. B. Redness and warmth at the site of the affected leg. C. Occasional cramping in the unaffected leg. D. Mild fatigue and generalized body aches.

Correct Answer is B

Explanation

A) This choice is incorrect because mild leg swelling after prolonged standing may be expected, especially in clients with a history of DVT. It is not a critical symptom to report immediately.

B) This choice is correct. Redness and warmth at the site of the affected leg could indicate an inflammatory response or progression of the clot. These signs may be indicative of a potential complication, such as an infection or extension of the clot, and should be reported immediately for further evaluation and intervention.

C) This choice is incorrect because occasional cramping in the unaffected leg may not be directly related to the DVT. While any changes in leg symptoms should be reported to the healthcare provider, this symptom is less urgent than redness and warmth in the affected leg.

D) This choice is incorrect because mild fatigue and generalized body aches are non-specific symptoms and may not be directly related to DVT. While it is essential to report any new or concerning symptoms, redness and warmth in the affected leg are more indicative of potential complications related to DVT.

Questions

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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?

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Naxlex Comprehensive Predictor Exams

A client with a history of deep vein thrombosis (DVT) asks the nurse about the causes of this condition. What is the nurse's best response?

Correct Answer is D

Explanation

A nurse is providing education to a client with deep vein thrombosis (DVT) about potential complications. Which symptom should the nurse instruct the client to report immediately?

Correct Answer is B

Explanation

A client with deep vein thrombosis (DVT) is being discharged from the hospital. What should the nurse include in the client's discharge teaching to promote ongoing preventive measures?

A nurse is caring for a client with suspected deep vein thrombosis (DVT). Which diagnostic test is used to assess blood flow and detect clots in the deep veins of the legs non-invasively?

A client with deep vein thrombosis (DVT) is prescribed anticoagulant therapy. What is the nurse's priority action in monitoring the client's response to the medication?

A nurse is explaining the diagnostic tests for deep vein thrombosis (DVT) to a client. Which test is considered the gold standard for diagnosing DVT?

A nurse is caring for a client receiving intravenous (IV) heparin therapy for deep vein thrombosis (DVT). What is the nurse's priority action to ensure safe administration of the medication?

A nurse is providing education to a client about the risk factors for deep vein thrombosis (DVT). Which client statement indicates an understanding of modifiable risk factors?

A client is admitted to the hospital with a suspected deep vein thrombosis (DVT). Which question should the nurse ask during the health history to identify potential risk factors for DVT?

A client is admitted to the hospital with symptoms suggestive of deep vein thrombosis (DVT). Which test can provide rapid results to rule out DVT and guide further diagnostic workup?