The nurse is reviewing the risk factors for a blood clot in a vein. Which of these situations can put a client at higher risk for developing a blood clot in a vein? Select all that apply.

immobility

smoking

history of stomach ulcers

overhydration

taking birth control pills

Answer and Explanation

Correct Answer : A,B,E

A. Immobility is a significant risk factor for venous thromboembolism (VTE) since prolonged inactivity can lead to stasis of blood flow, increasing clot formation risk.
B. Smoking contributes to hypercoagulability and vascular damage, both of which elevate the risk of clot formation in veins.
C. A history of stomach ulcers is not directly associated with an increased risk of blood clots; rather, it pertains more to gastrointestinal health.
D. Overhydration generally does not increase the risk of blood clots; rather, maintaining adequate hydration is important for circulation.
E. Taking birth control pills can increase the risk of blood clots due to hormonal changes that promote hypercoagulability.

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Correct Answer is ["A","C","D"]

Explanation

A. A febrile state indicates that the client may not be in an optimal condition to learn effectively, so postponing the session is appropriate.
B. Mild anxiety may not require postponement, as it can be addressed during teaching.
C. Nausea can significantly impair concentration and engagement in learning, warranting a delay.
D. A pain level of 8 out of 10 suggests significant discomfort, making it challenging for the client to focus on learning.
E. Asking questions indicates engagement and a readiness to learn, so this does not warrant postponing the session.

A. Decreased lung sounds on expiration B. Respirations are 40 breaths/minute C. Anterior-posterior diameter ratio is 1:1 D. Hyperresonance is noted to percussion E. Decreased tactile fremitus is present

Correct Answer is B

Explanation

A. Decreased lung sounds on expiration are common in COPD patients due to airway obstruction but do not necessarily indicate an acute issue.
B. Respirations are 40 breaths/minute is a critical finding, as this rapid respiratory rate suggests significant respiratory distress or worsening hypoxemia, which needs immediate intervention to prevent further complications.
C. An anterior-posterior diameter ratio of 1:1 (barrel chest) is a common finding in advanced COPD but does not indicate acute worsening.
D. Hyperresonance to percussion is typical in patients with COPD due to air trapping and does not suggest an immediate emergency.
E. Decreased tactile fremitus may occur in COPD due to increased air trapping but is not an urgent finding requiring immediate reporting.

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The nurse is reviewing the risk factors for a blood clot in a vein. Which of these situations can put a client at higher risk for developing a blood clot in a vein? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to teach clients. Which client finding will cause the nurse to postpone a teaching session? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?

Correct Answer is B

Explanation

A client asks the nurse to describe what causes a murmur. What would be the correct response by the nurse?

Which nonpharmacologic pain treatment should the nurse avoid using in an older adult who shows signs of confusion?

The nurse is reviewing the risk factors for a blood clot in a vein. Which of these situations can put a client at higher risk for developing a blood clot in a vein? Select all that apply.

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The nurse is asked to describe what the heart sound S2 represents. What would be the correct response by the nurse?

A client is admitted with a venous insufficiency of the right leg. What assessment findings does the nurse expect to find with this condition?