The nurse is evaluating a client for possible deep vein thrombosis (DVT). Which assessment should the nurse perform?

Inspect for distention of peripheral veins

Observe for change in breathing pattern

Palpate the volume of pedal pulses

Assess for inflammation of the calves

Answer and Explanation

The Correct Answer is D

Choice A reason: Inspecting peripheral vein distention assesses superficial thrombosis, not deep vein thrombosis (DVT), which occurs in deep veins like the femoral. DVT presents with calf inflammation, not visible vein distention, making this assessment less specific for diagnosing the condition’s classic signs.

Choice B reason: Observing breathing pattern changes detects pulmonary embolism, a DVT complication, not DVT itself. Calf inflammation is a primary DVT sign, and breathing changes are secondary, making this assessment irrelevant for initial DVT evaluation, focusing on systemic rather than localized findings.

Choice C reason: Palpating pedal pulses assesses arterial flow, not venous thrombosis. DVT causes calf inflammation and swelling, not pulse changes, unless severe. This assessment is less relevant, as DVT primarily affects venous return, making calf inflammation the priority for diagnosis.

Choice D reason: Assessing calf inflammation is critical, as DVT causes unilateral swelling, redness, and warmth due to venous obstruction. This classic sign, often with pain, directly indicates thrombus formation, making it the most specific assessment for diagnosing DVT and guiding anticoagulation therapy.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Teaching a family member to administer eye drops is important for post-discharge care but not immediate. Eye protection prevents injury post-surgery, and drops are nurse-administered in-hospital, making this intervention secondary to ensuring the surgical site’s safety.

Choice B reason: Providing an eye shield for sleeping is critical immediately, as the right eye is vulnerable to trauma post-glass removal. The shield prevents accidental rubbing or pressure, reducing infection or displacement risk, making it the priority intervention for postoperative protection.

Choice C reason: Deep breathing and coughing exercises prevent pulmonary issues in major surgeries, not minor eye procedures. These may increase intraocular pressure, risking surgical complications, making this intervention inappropriate and potentially harmful for eye surgery recovery.

Choice D reason: Obtaining vital signs every 2 hours monitors systemic stability but is not specific to eye surgery. Eye shield use prevents immediate trauma, and vital signs are secondary, as local protection is the priority post-glass removal to ensure healing.

A. Palpable cervical lymph node B. Carotid bruit C. Nuchal rigidity D. Jugular vein distention

Correct Answer is B

Explanation

Choice A reason: Palpable cervical lymph nodes suggest infection or malignancy, not stroke risk. Stroke is linked to vascular issues like carotid stenosis, detected by bruit. Lymph nodes are unrelated to cerebrovascular pathology, making this finding irrelevant for identifying stroke risk in the client.

Choice B reason: Carotid bruit indicates turbulent flow from stenosis, a major stroke risk due to potential embolism or reduced cerebral perfusion. This vascular finding directly correlates with ischemic stroke, making it the most critical assessment to report for stroke prevention and evaluation.

Choice C reason: Nuchal rigidity suggests meningitis or subarachnoid hemorrhage, not ischemic stroke risk. Carotid bruit is a specific precursor to embolic stroke, and nuchal rigidity addresses different neurological conditions, making this finding less relevant for stroke risk assessment.

Choice D reason: Jugular vein distention indicates heart failure or venous pressure, not arterial stroke risk. Carotid bruit directly relates to cerebrovascular disease, a stroke precursor, making jugular distention irrelevant, as it reflects cardiovascular, not cerebrovascular, pathology in stroke risk evaluation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is evaluating a client for possible deep vein thrombosis (DVT). Which assessment should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

Correct Answer is B

Explanation

The nurse reports that a client is at risk for a stroke based on which assessment finding?

Correct Answer is B

Explanation

A client is admitted to the intensive care unit (ICU) with a traumatic brain injury. Which invasive procedure should the nurse anticipate preparing the client to undergo?

The nurse is evaluating a client for possible deep vein thrombosis (DVT). Which assessment should the nurse perform?

A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client’s spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?

A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement?

During a preoperative assessment phone call, a client reports taking several “pills” every day. Which response should the office nurse provide?

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?