A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met?
Ambulates with assistance.
Oxygen saturation of 98%.
Pain of 2/10 after medication.
Verbalizing risk factors.
The Correct Answer is B
Choice A rationale
Ambulating with assistance is not an immediate indicator of a positive outcome for a client with a DVT. Ambulation is often contraindicated in the initial stages of treatment to prevent a pulmonary embolism. Therefore, this assessment does not reflect a primary outcome of DVT management, which focuses on preventing complications and resolving the clot.
Choice B rationale
An oxygen saturation of 98% is a critical indicator that the client has not developed a pulmonary embolism, a serious and life-threatening complication of DVT. This outcome demonstrates that the thrombus has not dislodged and traveled to the lungs, obstructing gas exchange. Normal oxygen saturation levels range from 95% to 100%.
Choice C rationale
While pain reduction is an important aspect of care, a pain score of 2/10 after medication is a temporary relief measure and does not represent a definitive outcome for DVT. The primary goal is to prevent a pulmonary embolism and resolve the thrombus, and pain control is a supportive measure in achieving that goal.
Choice D rationale
Verbalizing risk factors indicates that the client has received education, which is an important intervention. However, it is an educational outcome, not a physiological one. It does not provide direct evidence that the DVT is resolving or that the client is free from the most serious complication of the disease, a pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Infant skin has greater perfusion compared to adult skin due to a higher ratio of capillaries to surface area. This increased blood flow contributes to the infant's ability to dissipate heat but also makes their skin more susceptible to flushing and temperature changes.
Choice B rationale
While infants have a higher percentage of total body water, their stratum corneum, the outermost layer of skin, is thinner and has a lower lipid content, leading to a higher transepidermal water loss compared to adults. This makes their skin more prone to dryness.
Choice C rationale
Infants have a higher density of eccrine sweat glands, but their thermoregulatory system is immature. They are less efficient at perspiring and have a higher risk of hyperthermia. Their sweat glands are not fully developed or functional, which is different from increased perspiration.
Choice D rationale
Infant skin has a thinner stratum corneum and a higher surface area-to-weight ratio compared to adult skin. This anatomical difference results in a greater percutaneous absorption of topical medications and other substances. This is why care must be taken with the amount of medication applied.
Correct Answer is A
Explanation
Choice A rationale
A blood pressure of 98/58 mm Hg in a client who needs a beta blocker is a significant safety concern. Beta blockers work by blocking the effects of epinephrine, which can cause a decrease in heart rate and blood pressure. Administering a beta blocker to a client with a pre-existing low blood pressure (normotensive range is 120/80 mm Hg) could cause a profound and dangerous drop in blood pressure, leading to hypotension, syncope, and inadequate organ perfusion. This client needs immediate assessment before medication administration.
Choice B rationale
A client needing to use the bathroom after taking captopril is not an immediate priority. While captopril can cause hypotension, the primary concern is the potential for a first-dose hypotensive effect. However, a client's need to void is a common and expected request and does not indicate an acute, life-threatening crisis requiring immediate intervention before other clients.
Choice C rationale
A blood pressure of 188/92 mm Hg, while elevated, is not an immediate life-threatening emergency unless there are signs of end-organ damage (e.g., chest pain, neurological changes). This is considered a hypertensive urgency, which requires a prompt but not immediate intervention to lower the blood pressure gradually. This client is stable and can be assessed after the client in Choice A, who is at risk for a profound hypotensive event.
Choice D rationale
A client needing pain medication before a dressing change is not the highest priority. Pain management is an important aspect of care, but it is not an acute physiological emergency. Delaying pain medication for a short time to address a life-threatening physiological instability in another client is an appropriate triage decision. The client in Choice A is at higher risk for a critical physiological event. .
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