H&I EXAM 3: DVT QUESTIONS AND
ANSWERS
The nurse is assessing a postpartum woman and determines that the client may have a
deep venous thrombosis (DVT) when the nurse notes which of the following
manifestations?
1.Pain located in the foot
2.Pain in the abdomen
3.Ankle and leg edema
4.Positive pulses in the affected leg - Correct Answers -3.Ankle and leg edema
DVT usually presents as leg and ankle edema, not as pain in the foot. Abdominal pain is
not indicative of a leg DVT. The affected leg may or may not have pulses; this is not a
good indicator of DVT.
The nurse teaches the family of an older client who is at risk for developing deep
venous thrombosis (DVT) about prevention of the condition. Which of the following will
the nurse include in the teaching?
1.Place pillows under the knees so that hips are flexed.
2.Apply elastic hose if swelling develops.
3.Position client to promote venous return.
4.Keep feet squarely on the floor when sitting in a chair. - Correct Answers -3.Position
client to promote venous return.
The client should be positioned to promote venous return. Flexing the hips promotes
pooling of venous blood in the leg and impedes venous return. If ordered, elastic hose
are worn 23 of 24 hours per day. When seated, the client should use a footstool or a
recliner chair.
The partner of a client with disseminated intravascular coagulation (DIC) approaches
the nurse with concern because the client has been placed on heparin therapy. The
partner states, "I thought the problem was too much bleeding. Doesn't heparin make an
individual bleed more?" The best response by the nurse is which of the following?
1."I understand your concern but the doctors know what they are doing."
2."Let me make sure I have not misread the doctor's orders."
3."The drug is being used to stop abnormal clotting in the capillaries and arterioles."
4."Please talk to the physician about why this drug is being used." - Correct Answers -
1."The drug is being used to stop abnormal clotting in the capillaries and arterioles."
In DIC, there is an initial enhanced coagulation mechanism with resulting increase in
fibrin and platelet deposition in capillaries and arterioles, resulting in thrombosis. Use of
heparin is aimed at preventing the formation of additional thrombi.Explaining the use of
,the medication is far more therapeutic than saying that the doctors know what they are
doing or that the nurse might have misread the order. It is not an option for the nurse to
send the partner to the physician as the nurse should understand the disease and the
reason for treatment.
The nurse is caring for a client with a deep venous thrombosis (DVT) and selects
Ineffective Tissue Perfusion as a priority nursing diagnosis based on which of the
following assessments?
1.Mild, aching pain described by the client
2.Temperature of 102°F
3.Heart rate of 62
4.Pallor and warmth of the affected leg - Correct Answers -1.Pallor and warmth of the
affected leg
With a DVT, the blood pools in the leg and flow in the leg is impeded. The client's leg
will be swollen, pale, and cool to the touch. The client's pain is not an objective
assessment by the nurse; though pain can be either mild and achy or severe and sharp,
this is not diagnostic of DVT and is not a reliable indicator of DVT.The client may have a
low-grade temperature, but not a high fever. The heart rate is not an indicator of DVT.
The nurse is carefully monitoring a postpartum client who experienced abruptio
placentae for which of the following signs of disseminated intravascular coagulation
(DIC)?
1.Pain and swelling in the leg
2.Rapid clotting times
3.Increased platelet levels
4.Petechiae, oozing from injection sites, and hematuria - Correct Answers -1.Petechiae,
oozing from injection sites, and hematuria
Petechiae, oozing from injection sites, and hematuria are signs of DIC. Pain and
swelling in the leg indicate thrombophlebitis. The client's clotting times would be
prolonged in DIC, and platelet levels would be decreased.
The nurse will explain the risk factors for disseminated intravascular coagulation (DIC)
to the family of the client who has experienced which of the following?
1.Trauma
2.Urinary tract infection
3.Cellulitis
4.Otitis media - Correct Answers -1.Trauma
Clients with trauma such as burns and gunshot wounds are at risk for DIC. Urinary tract
infection, cellulitis, and otitis media are not considered risks for DIC unless the client
develops sepsis from one of these.
DIC and Pregnancy causes - Correct Answers -Retention of a dead fetus or injury
Toxemia
Amniotic fluid embolus
,Placental abruption
Preeclampsia
Placental retention
Bacterial sepsis
DIC in pregnancy treatment - Correct Answers -Deliver baby
PRBC
FFP
Cryoprecipitate
Pitocin
Heparin as ordered
Monitor fetus for DIC
When was MRSA discovered? - Correct Answers -1961
MRSA is resistant to - Correct Answers -methicillin, amoxicillin, penicillin, oxacillin, and
other common antibiotics known as cephalosporins.
What is methicillin-resistant Staphylococcus aureus (MRSA) - Correct Answers -MRSA
is a bacterium that causes infections in different parts of the body. It's tougher to treat
than most strains of staphylococcus aureus -- or staph -- because it's resistant to some
commonly used antibiotics
A client has disseminated intravascular coagulation (DIC). Which clinical manifestation
should the nurse expect to observe? (Select all that apply.)
Question content area bottom
Part 1
A.
Hypertension
B.
Bleeding
C.
Clotting
D.
Petechiae
E.
Joint pain - Correct Answers -B.
Bleeding
C.
Clotting
D.
Petechiae
E.
Joint pain
, The client with which condition is at the greatest risk of developing acute disseminated
intravascular coagulation?
Question content area bottom
Part 1
A.
Gunshot wound to the distal arm
B.
Third-degree burns and septic shock
C.
Bacterial pneumonia treated with antibiotics
D.
Aortic aneurysm - Correct Answers -B.
Third-degree burns and septic shock
The nurse concludes that both clotting and bleeding occur during disseminated
intravascular coagulation (DIC) due to which process?
Question content area bottom
Part 1
A.
Only clotting occurs during DIC, as clotting factors are replaced and available to prevent
excess bleeding.
B.
Excess release of thrombin uses up clotting factors quicker than they can be replaced.
C.
Tissue damage from bleeding uses up clotting factors quicker than they can be
replaced.
D.
Activation of intrinsic pathways results in release of excess clotting factors. - Correct
Answers -B.
Excess release of thrombin uses up clotting factors quicker than they can be replaced.
Disseminated intravascular coagulation (DIC) is triggered by an injury or agent that
activates the clotting cascade. Which condition should the nurse identify as a trigger for
the clotting cascade? (Select all that apply.)
Question content area bottom
Part 1
A.
Acute leukemia
B.
Head injury
C.
Acute glomerulonephritis
D.
Bacterial infection
E.
Placenta previa - Correct Answers -A.
ANSWERS
The nurse is assessing a postpartum woman and determines that the client may have a
deep venous thrombosis (DVT) when the nurse notes which of the following
manifestations?
1.Pain located in the foot
2.Pain in the abdomen
3.Ankle and leg edema
4.Positive pulses in the affected leg - Correct Answers -3.Ankle and leg edema
DVT usually presents as leg and ankle edema, not as pain in the foot. Abdominal pain is
not indicative of a leg DVT. The affected leg may or may not have pulses; this is not a
good indicator of DVT.
The nurse teaches the family of an older client who is at risk for developing deep
venous thrombosis (DVT) about prevention of the condition. Which of the following will
the nurse include in the teaching?
1.Place pillows under the knees so that hips are flexed.
2.Apply elastic hose if swelling develops.
3.Position client to promote venous return.
4.Keep feet squarely on the floor when sitting in a chair. - Correct Answers -3.Position
client to promote venous return.
The client should be positioned to promote venous return. Flexing the hips promotes
pooling of venous blood in the leg and impedes venous return. If ordered, elastic hose
are worn 23 of 24 hours per day. When seated, the client should use a footstool or a
recliner chair.
The partner of a client with disseminated intravascular coagulation (DIC) approaches
the nurse with concern because the client has been placed on heparin therapy. The
partner states, "I thought the problem was too much bleeding. Doesn't heparin make an
individual bleed more?" The best response by the nurse is which of the following?
1."I understand your concern but the doctors know what they are doing."
2."Let me make sure I have not misread the doctor's orders."
3."The drug is being used to stop abnormal clotting in the capillaries and arterioles."
4."Please talk to the physician about why this drug is being used." - Correct Answers -
1."The drug is being used to stop abnormal clotting in the capillaries and arterioles."
In DIC, there is an initial enhanced coagulation mechanism with resulting increase in
fibrin and platelet deposition in capillaries and arterioles, resulting in thrombosis. Use of
heparin is aimed at preventing the formation of additional thrombi.Explaining the use of
,the medication is far more therapeutic than saying that the doctors know what they are
doing or that the nurse might have misread the order. It is not an option for the nurse to
send the partner to the physician as the nurse should understand the disease and the
reason for treatment.
The nurse is caring for a client with a deep venous thrombosis (DVT) and selects
Ineffective Tissue Perfusion as a priority nursing diagnosis based on which of the
following assessments?
1.Mild, aching pain described by the client
2.Temperature of 102°F
3.Heart rate of 62
4.Pallor and warmth of the affected leg - Correct Answers -1.Pallor and warmth of the
affected leg
With a DVT, the blood pools in the leg and flow in the leg is impeded. The client's leg
will be swollen, pale, and cool to the touch. The client's pain is not an objective
assessment by the nurse; though pain can be either mild and achy or severe and sharp,
this is not diagnostic of DVT and is not a reliable indicator of DVT.The client may have a
low-grade temperature, but not a high fever. The heart rate is not an indicator of DVT.
The nurse is carefully monitoring a postpartum client who experienced abruptio
placentae for which of the following signs of disseminated intravascular coagulation
(DIC)?
1.Pain and swelling in the leg
2.Rapid clotting times
3.Increased platelet levels
4.Petechiae, oozing from injection sites, and hematuria - Correct Answers -1.Petechiae,
oozing from injection sites, and hematuria
Petechiae, oozing from injection sites, and hematuria are signs of DIC. Pain and
swelling in the leg indicate thrombophlebitis. The client's clotting times would be
prolonged in DIC, and platelet levels would be decreased.
The nurse will explain the risk factors for disseminated intravascular coagulation (DIC)
to the family of the client who has experienced which of the following?
1.Trauma
2.Urinary tract infection
3.Cellulitis
4.Otitis media - Correct Answers -1.Trauma
Clients with trauma such as burns and gunshot wounds are at risk for DIC. Urinary tract
infection, cellulitis, and otitis media are not considered risks for DIC unless the client
develops sepsis from one of these.
DIC and Pregnancy causes - Correct Answers -Retention of a dead fetus or injury
Toxemia
Amniotic fluid embolus
,Placental abruption
Preeclampsia
Placental retention
Bacterial sepsis
DIC in pregnancy treatment - Correct Answers -Deliver baby
PRBC
FFP
Cryoprecipitate
Pitocin
Heparin as ordered
Monitor fetus for DIC
When was MRSA discovered? - Correct Answers -1961
MRSA is resistant to - Correct Answers -methicillin, amoxicillin, penicillin, oxacillin, and
other common antibiotics known as cephalosporins.
What is methicillin-resistant Staphylococcus aureus (MRSA) - Correct Answers -MRSA
is a bacterium that causes infections in different parts of the body. It's tougher to treat
than most strains of staphylococcus aureus -- or staph -- because it's resistant to some
commonly used antibiotics
A client has disseminated intravascular coagulation (DIC). Which clinical manifestation
should the nurse expect to observe? (Select all that apply.)
Question content area bottom
Part 1
A.
Hypertension
B.
Bleeding
C.
Clotting
D.
Petechiae
E.
Joint pain - Correct Answers -B.
Bleeding
C.
Clotting
D.
Petechiae
E.
Joint pain
, The client with which condition is at the greatest risk of developing acute disseminated
intravascular coagulation?
Question content area bottom
Part 1
A.
Gunshot wound to the distal arm
B.
Third-degree burns and septic shock
C.
Bacterial pneumonia treated with antibiotics
D.
Aortic aneurysm - Correct Answers -B.
Third-degree burns and septic shock
The nurse concludes that both clotting and bleeding occur during disseminated
intravascular coagulation (DIC) due to which process?
Question content area bottom
Part 1
A.
Only clotting occurs during DIC, as clotting factors are replaced and available to prevent
excess bleeding.
B.
Excess release of thrombin uses up clotting factors quicker than they can be replaced.
C.
Tissue damage from bleeding uses up clotting factors quicker than they can be
replaced.
D.
Activation of intrinsic pathways results in release of excess clotting factors. - Correct
Answers -B.
Excess release of thrombin uses up clotting factors quicker than they can be replaced.
Disseminated intravascular coagulation (DIC) is triggered by an injury or agent that
activates the clotting cascade. Which condition should the nurse identify as a trigger for
the clotting cascade? (Select all that apply.)
Question content area bottom
Part 1
A.
Acute leukemia
B.
Head injury
C.
Acute glomerulonephritis
D.
Bacterial infection
E.
Placenta previa - Correct Answers -A.
