The nurse is caring for a client who is being evaluated for possible deep vein thrombosis of the right extremity. Which laboratory result is of most concern to the nurse?

Activated Partial Thromboplastin Time (aPTT) of 25.

D-dimer of 500 ng/mL.

Prothrombin Time (PT) of 14 seconds.

Platelet count of 148,000 uL.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Activated Partial Thromboplastin Time (aPTT) of 25 is within the normal range (25-35 seconds) and is not directly related to deep vein thrombosis (DVT)89.

Choice B rationale

A D-dimer level of 500 ng/mL is elevated (normal range is typically less than 250 ng/mL), which can indicate the presence of a clot, such as in DVT8910.

Choice C rationale

Prothrombin Time (PT) of 14 seconds is within the normal range (11-13.5 seconds) and is not directly related to DVT89.

Choice D rationale

A platelet count of 148,000 uL is within the normal range (150,000-450,000 uL) and is not directly related to DVT89.

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Correct Answer is A

Explanation

Choice A rationale

When a patient is informed about a serious diagnosis like breast cancer and the need for a mastectomy, it is common for them to experience a range of emotions, including sadness, fear, and anxiety. As a nurse, providing emotional support and creating a safe space for the patient to express their feelings is crucial. Offering to be there for the patient if they want to talk acknowledges their emotional distress and provides comfort.

Choice B rationale

Asking the patient why they are upset may come across as insensitive or dismissive. The patient has just received a life-changing diagnosis, and their emotional reaction is completely normal and expected. It’s important to provide support and empathy rather than questioning their feelings.

Choice C rationale

Telling the patient that everything will be alright and there is no need to cry may seem comforting, but it can actually invalidate the patient’s feelings. It’s important to acknowledge the patient’s emotions and allow them to express their feelings without judgment.

Choice D rationale

Telling the patient that they will recover may be seen as providing false reassurance. While it’s important to maintain hope, it’s also crucial to be honest and realistic with the patient about their diagnosis and treatment.

A. Administer morphine 2-4 mg IV prn for pain. B. Apply a figure of 8 pressure dressing starting day two post-operatively. C. Administer antibiotics as prescribed. D. Apply ice to the stump for 60-90 minutes.

Correct Answer is A

Explanation

The correct answer is Choice A. After a below-the-knee amputation (BKA), pain management is crucial. Administering morphine 2-4 mg IV prn for pain is an appropriate physician’s order to implement. Pain can be severe after amputation, and effective pain management can improve patient comfort, reduce anxiety, and aid in recovery. Applying a figure of 8 pressure dressing starting day two post-operatively (Choice B) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact. Administering antibiotics as prescribed (Choice C) is important, but it is not the first action to take. Pain management is the priority immediately after surgery. Applying ice to the stump for 60-90 minutes (Choice D) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.

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The nurse is caring for a client who is being evaluated for possible deep vein thrombosis of the right extremity. Which laboratory result is of most concern to the nurse?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician has just informed a patient that they have breast cancer and will require a mastectomy. The nurse finds that the patient is crying. Which response by the nurse is most appropriate?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A client with diabetes has returned from the post-anesthesia care unit (PACU) after a below-the-knee amputation (BKA) of the left leg. Which physician’s order should the nurse implement?

Correct Answer is A

Explanation

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The nurse is caring for a client who is being evaluated for possible deep vein thrombosis of the right extremity. Which laboratory result is of most concern to the nurse?

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