Question 1 of 70
Exhibit 1
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Vital Signs
Blood pressure 130/72 mm Hg
Heart rate 90/min
Respiratory rate 18/min
Temperature 37°C (98.6°F)
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each findings, click to specify whether the finding is unrelated to the diagnosis, an indication of
potential
improvement, or an indication of potential worsening condition.
Findings 24 hr later Unrelated to diagnosis S alpoient'el
improvement
Redness in the \/
extremity
Increased warmth in the \/
extremity
Decreased extremity \/
edema
Tachycardia \/
Scant lochia rubra \\//
leukocytosis
Exhibit 2
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Medical History
Gravida 2 Para 2
Cesarean birth
Deep vein thrombosis with previous pregnancy
Preeclampsia
,BMI of 32
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each findings, click to specify whether the finding is unrelated to the diagnosis, an indication of
potential improvement, or an indication of potential worsening condition.
Redness in
the \/
extremity
Increased
warmth in 4
the
extremity
Decreased
extremity ‘/
edema
Tachycardia \/
Scant lochia v
rubra
leukocytosis v
Exhibit 3
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Diagnostic Results
Doppler ultrasound indicative of deep vein blockage
Positive D-dimer
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each findings, click to specify whether the finding is unrelated to the diagnosis, an indication of
potential improvement, or an indication of potential worsening condition.
, Redness
in the V4
extremity
Increased
warmth v
in the
extremity
Decreased \/
extremity V4
edema
Tachycardia v
Scant lochia V4
rubra
leukocytosis \/
Question 5
Exhibit 4
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Medication Administration Record
Acetaminophen 1,000 mg IV every 6 hr
Nifedipine 20 mg/capsule PO twice per day
Heparin 25,000 units per 250 mL of 0.45% sodium chloride IV to infuse at 1,000 units/hr for 24 hr.
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each findings, click to specify whether the finding is unrelated to the diagnosis, an indication of
potential improvement, or an indication of potential worsening condition.
Redness in
the v
extremity
Increased
warmth in \/
the
extremity
, Decreased
extremity v
edema
Tachycardia V4
Scant lochia
rubra v
leukocytosis v
Question 2 of 70
Exhibit 1
A nurse is caring for a newborn who is 4 hr old.
Nurses’ Notes
Newborn is lying in bassinet, lightly swaddled.
Newborn is noted to be jittery with a weak cry when disturbed.
Extremities are mottled with acrocyanosis
Respirations are rapid and unlabored
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse
should monitor to assess the client’s progress.
Potential Condition: Congenital Syphilis
Parameter 1: Sking integrity
Parameter 2: Respiratory status
Exhibit 1
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Vital Signs
Blood pressure 130/72 mm Hg
Heart rate 90/min
Respiratory rate 18/min
Temperature 37°C (98.6°F)
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each findings, click to specify whether the finding is unrelated to the diagnosis, an indication of
potential
improvement, or an indication of potential worsening condition.
Findings 24 hr later Unrelated to diagnosis S alpoient'el
improvement
Redness in the \/
extremity
Increased warmth in the \/
extremity
Decreased extremity \/
edema
Tachycardia \/
Scant lochia rubra \\//
leukocytosis
Exhibit 2
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Medical History
Gravida 2 Para 2
Cesarean birth
Deep vein thrombosis with previous pregnancy
Preeclampsia
,BMI of 32
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each findings, click to specify whether the finding is unrelated to the diagnosis, an indication of
potential improvement, or an indication of potential worsening condition.
Redness in
the \/
extremity
Increased
warmth in 4
the
extremity
Decreased
extremity ‘/
edema
Tachycardia \/
Scant lochia v
rubra
leukocytosis v
Exhibit 3
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Diagnostic Results
Doppler ultrasound indicative of deep vein blockage
Positive D-dimer
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each findings, click to specify whether the finding is unrelated to the diagnosis, an indication of
potential improvement, or an indication of potential worsening condition.
, Redness
in the V4
extremity
Increased
warmth v
in the
extremity
Decreased \/
extremity V4
edema
Tachycardia v
Scant lochia V4
rubra
leukocytosis \/
Question 5
Exhibit 4
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
Medication Administration Record
Acetaminophen 1,000 mg IV every 6 hr
Nifedipine 20 mg/capsule PO twice per day
Heparin 25,000 units per 250 mL of 0.45% sodium chloride IV to infuse at 1,000 units/hr for 24 hr.
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each findings, click to specify whether the finding is unrelated to the diagnosis, an indication of
potential improvement, or an indication of potential worsening condition.
Redness in
the v
extremity
Increased
warmth in \/
the
extremity
, Decreased
extremity v
edema
Tachycardia V4
Scant lochia
rubra v
leukocytosis v
Question 2 of 70
Exhibit 1
A nurse is caring for a newborn who is 4 hr old.
Nurses’ Notes
Newborn is lying in bassinet, lightly swaddled.
Newborn is noted to be jittery with a weak cry when disturbed.
Extremities are mottled with acrocyanosis
Respirations are rapid and unlabored
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse
should monitor to assess the client’s progress.
Potential Condition: Congenital Syphilis
Parameter 1: Sking integrity
Parameter 2: Respiratory status
