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 A
Explanation
Choice A rationale
Certain broad-spectrum antibiotics, such as tetracyclines, can alter the gut flora responsible for enterohepatic circulation of estrogens. This disruption can reduce the reabsorption of ethinyl estradiol, the synthetic estrogen in oral contraceptives, from the gut. The decreased serum levels of the hormone may lead to a reduction in the contraceptive's effectiveness, increasing the risk of unintended pregnancy. A backup birth control method should be used.
Choice B rationale
Urinary burning and frequency are more commonly associated with urinary tract infections (UTIs) or some sexually transmitted infections, and not a typical side effect of antibiotics used for acne like tetracyclines or minocycline. These symptoms would indicate an inflammatory process in the urinary tract, which is distinct from the mechanism of action and side effect profile of these specific antibiotics.
Choice C rationale
Breast engorgement is a physiological condition often associated with hormonal fluctuations during the postpartum period or premenstrually. It is not a recognized side effect of systemic antibiotics used to treat acne. The mechanism of action of these medications does not involve hormonal pathways that would lead to breast tissue swelling and tenderness.
Choice D rationale
While some antibiotics can predispose to vaginal yeast infections (vaginitis) by disrupting the normal vaginal flora, this is not a side effect of all antibiotics used for acne. The reduction of beneficial lactobacilli can allow for an overgrowth of Candida albicans, leading to symptoms like itching and discharge, which is a known risk with some antibiotic classes but not a universal side effect across all.
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.
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