The nurse is caring for the following four clients on the nursing unit.
Which client is at the highest risk for the development of deep vein thrombosis?
55-year-old man with a past medical history of a myocardial infarction.
45-year-old woman post laparoscopic knee replacement.
65-year-old woman post major open abdominal surgery.
50-year-old man with a peptic ulcer.
The Correct Answer is C
Choice A rationale
While a past medical history of myocardial infarction does increase the risk of deep vein thrombosis (DVT), it is not the highest risk factor among the options provided. Other factors such as immobility, surgery, and certain medical conditions can pose a higher risk.
Choice B rationale
Postoperative patients, such as those who have had a laparoscopic knee replacement, are at an increased risk for DVT due to periods of immobility and changes in blood flow and clotting.
However, the risk is not as high as in patients who have undergone major open abdominal surgery.
Choice C rationale
Patients who have undergone major open abdominal surgery are at the highest risk for the development of DVT among the options provided. The surgery itself, along with the postoperative period of immobility, significantly increases the risk of DVT34567.
Choice D rationale
While peptic ulcers can be associated with certain risk factors for DVT, such as age and immobility due to pain, they do not pose as high a risk as major open abdominal surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Dark urine can be a sign of liver dysfunction, which can be a side effect of glipizide. Therefore, reviewing the results of liver function studies would be an appropriate initial action to determine if the medication is affecting the client’s liver function.
Choice B rationale
While increasing water intake can sometimes help with certain side effects of medications, it would not address the potential issue of liver dysfunction indicated by the dark urine.
Choice C rationale
Checking the client’s weight would not provide information related to the cause of the dark urine.
Choice D rationale
Testing a sample of urine for the presence of occult blood could be useful if there was a suspicion of bleeding, but it would not address the potential issue of liver dysfunction indicated by the dark urine.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Proteins, vitamin C, and zinc are essential for wound healing. Proteins are the building blocks for body tissue, and zinc plays a role in protein synthesis. Vitamin C is needed for the formation of collagen, a protein used to make skin, scar tissue, and blood vessels.
Choice B rationale
Care should be taken when walking to avoid bumping the limb. Any trauma to the affected limb could potentially worsen the condition or delay healing.
Choice C rationale
Cleaning the ulcer with soap and water may not be the best option. Soap can be irritating to the skin and may delay healing. Instead, the ulcer should be cleaned as per healthcare provider’s instructions.
Choice D rationale
Cortisone cream is not typically used for venous stasis ulcers. It can thin the skin and delay healing.
Choice E rationale
Compression stockings are often recommended for patients with post-thrombotic syndrome. They can help reduce swelling and improve blood flow, which can promote healing of the venous stasis ulcer.
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