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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.

Choice B rationale

Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.

Choice C rationale

Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.

Choice D rationale

Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow.

However, this symptom does not require immediate intervention but should be evaluated further.

A. Administer the prescribed antibiotic early. B. Apply a sterile dressing to the area. C. Report the finding to the care provider. D. Obtain a culture of the incision.

Correct Answer is C

Explanation

Choice A rationale

Administering the prescribed antibiotic early might not be the most immediate action. While antibiotics can help treat an infection, it’s crucial to first confirm the presence of an infection before starting antibiotic therapy.

Choice B rationale

Applying a sterile dressing to the area is important, but it’s not the priority nursing action. Dressings help protect the wound from further contamination, but they do not address the underlying issue of a potential infection.

Choice C rationale

Reporting the finding to the care provider is the priority nursing action. The symptoms described - a new foul odor coming from the incision, which is erythematous, tender, and warm to the touch - suggest a possible infection. Immediate reporting allows for prompt evaluation and treatment, which is crucial in preventing further complications.

Choice D rationale

Obtaining a culture of the incision might be necessary to identify the specific causative agent of the infection, but it’s not the priority action. It’s more important to first report the findings to the care provider.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a diagnosis of chronic peripheral arterial disease. Which statement by the patient warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is caring for a patient who had an above-the-knee amputation (AKA) five days ago. The nurse notices a new foul odor coming from the incision, which is erythematous, tender, and warm to the touch. What is the priority nursing action in this situation?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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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?