A nurse is assessing a client for deep vein thrombosis (DVT). Which assessment technique should the nurse prioritize to identify DVT-related clinical manifestations?
Palpating the pulses in the extremities.
Measuring calf and thigh circumference.
Auscultating the lungs for crackles.
Performing a capillary refill test.
The Correct Answer is B
A) This choice is incorrect because palpating the pulses in the extremities primarily assesses arterial blood flow, not venous thrombosis. While pulse assessment is essential, it is not the priority for identifying DVT-related manifestations.
B) This choice is correct. Measuring calf and thigh circumference can help identify possible DVT by comparing the affected leg's size to the unaffected one. DVT can cause localized swelling in the affected limb.
C) This choice is incorrect because auscultating the lungs for crackles is not a specific assessment for DVT. Crackles may be present in pulmonary edema, which can be a complication of DVT, but they do not directly assess the presence of a blood clot in the veins.
D) This choice is incorrect because performing a capillary refill test is primarily used to assess peripheral perfusion and is not specific to DVT assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A) This choice is incorrect because advanced age is a non-modifiable risk factor for DVT. While age is associated with increased risk, it is not directly related to the client's use of hormonal therapy.
B) This choice is incorrect because male gender is not a risk factor for DVT. Women, particularly those on estrogen-based therapies like hormone replacement therapy or oral contraceptives, are at higher risk.
C) This choice is incorrect because smoking history is a modifiable risk factor for DVT, not directly related to hormonal therapy. Smoking increases the risk of clot formation and is not specific to the client's use of hormonal therapy.
D) This choice is correct. Estrogen-based hormone replacement therapy and oral contraceptives can increase the risk of DVT due to their effect on blood coagulation. Estrogen can increase the production of certain clotting factors, raising the risk of blood clot formation in the veins. It is essential for healthcare providers to weigh the benefits and risks when prescribing hormonal therapy to clients.
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