A nurse is caring for a 75-year-old client who is admitted to the medical- surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Most Likely Condition: Deep Vein Thrombosis (DVT)
The client has multiple risk factors for developing a Deep Vein Thrombosis (DVT
•   Recent surgery: The client is 2 days postoperative following a hysterectomy, which increases the risk of blood clots.
•   Obesity: The client’s weight is 121.3 kg (267.4 lb), which significantly increases the risk of DVT
due to poor circulation and reduced mobility.
•   Physical inactivity: The client has not yet ambulated much post-surgery due to significant pain, leading to stasis of blood in the lower extremities, which can increase the risk of clots.

•   Smoking history: Smoking can damage blood vessels and increase clotting risk.
•   Noncompliance with sequential compression devices (SCDs): The client reports that SCDs "hurt too much," and as a result, they are not wearing them. SCDs are a key prevention strategy against DVT, so nonuse of them further increases the risk.

Actions to Take

Check for pedal pulses and signs of ischemia:
DVT can lead to impaired circulation and ischemia in the affected limb. The nurse should assess for pedal pulses and signs of ischemia (e.g., coldness, swelling, pallor) to evaluate the extent of blood flow to the lower extremities. Early detection of impaired circulation can prevent complications like tissue damage.
Request a prescription for a lower-extremity Doppler flow study:
A Doppler ultrasound is the gold standard for diagnosing DVT. This non-invasive test uses sound waves to assess blood flow and detect clots. It should be ordered if the nurse suspects a DVT, especially with the client’s high risk factors.

Parameters to Monitor

Signs of bleeding after anticoagulation initiation:
If the client is diagnosed with a DVT, anticoagulants (e.g., heparin, warfarin, or enoxaparin) are often prescribed to prevent the clot from growing or migrating. The nurse needs to monitor for signs of bleeding (e.g., unusual bruising, bloody stools, or hematuria) as anticoagulant therapy increases bleeding risk.
Temperature:
Fever can be an indicator of infection or inflammation. If a DVT becomes complicated by phlebitis (inflammation of the vein) or if the clot is large or causes an infection, the client may develop a fever. Regular temperature monitoring is essential for detecting early signs of infection or complications related to DVT.

Rationale for incorrect conditions;
Muscle strain: While muscle strain can occur, the client’s presentation and risk factors (recent surgery, immobility, obesity) align more with DVT. Muscle strain is usually associated with localized pain, whereas DVT often presents with swelling, pain, and redness in the lower extremity, and potentially warmth.
Cellulitis: This is an infection of the skin and underlying tissues, typically presenting with redness, swelling, and warmth. The client does not exhibit these symptoms, and there’s no indication of an infection in the notes.
Heart failure: Heart failure can cause fluid retention, which leads to swelling in the extremities, but the
client’s vital signs (e.g., normal BP, heart rate, and respiratory rate) do not suggest heart failure. Additionally, the client does not report symptoms such as shortness of breath or chest pain.

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Correct Answer is A

Explanation

A. A noncoring needle is specifically designed to access venous access ports without damaging the port, making it the appropriate choice.
B. An angiocatheter is used for peripheral IV insertion, not for accessing an implanted port.
C. A butterfly needle is used for short-term venous access, not for implanted ports.
D. A 25-gauge needle is too small for accessing an implanted port and would not be effective.

A. Negligence B. Battery C. Malpractice D. Assault

Correct Answer is D

Explanation

A. Negligence involves a failure to provide reasonable care, but it does not apply here since the AP’s
actions were intentional.
B. Battery is the intentional and harmful physical contact with another person without their consent. In the context of healthcare, this could involve actions like physically restraining a patient without consent, administering medication without consent, or any physical contact that is deemed offensive and unwarranted.
C. Malpractice refers to professional negligence by a healthcare provider, which is not the case here.
D. Assault occurs when there is an intentional act that creates a fear of imminent harmful or offensive contact with another person, even if no actual physical contact occurs. In this case, the AP's statement, "If you don't eat, I'll put restraints on your wrists and feed you," is a verbal threat of harm.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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