DEEP VEIN THROMBOSIS QUESTIONS AND
ANSWERS CORRECT ANSWERS AND
SOLUTIONS
◉ Meet the Client (scenario). Answer: The client is recovering from
hip fracture surgery less than 3 months ago. She has a history of
rheumatoid arthritis and stated that she fell while mopping her kitchen
floor fracturing her right hip and required surgery. The client received
prophylactic enoxaparin injections while hospitalized and continued
to self-administer the injections upon discharge home as prescribed.
The last injection was one month ago. The client reports that her right
leg began swelling a few days ago and is now quite painful at a pain
level 7/10. Her spouse drove her to the Peripheral Vascular Clinic to
have her leg examined. The health care provider (HCP) at the clinic
performed diagnostics and suspects a deep vein thrombosis (DVT).
He prescribed a transfer for the client to be admitted to the inpatient
setting for further diagnostics and treatment. The client states she
feels anxious about being admitted to the hospital.
◉ Assessment. Answer: Vital signs: blood pressure 160/82 mmHg,
heart rate 80 beats/min., temperature 100o F (37.78o C), respiratory
rate 16 breaths/min., oxygen saturation 98% on room air5 ft. 2 in
(157.48 cm)/ weighs 165 lbs. (84.09 kg)Breath sounds clear upon
auscultation with bilaterally equal expansion.Respirations regular
with no dyspnea or cough.Right lower extremity: edematous,
erythema, tenderness, warmthClient states pain level is 7/10.Pedal
pulses normal 2+ bilaterally with capillary refill greater than 3.Client
reports that her leg has been painful since the previous evening.Client
,reports severe pain in her foot and ankle.Client has a history of taking
oral contraceptives.Client has a history of rheumatoid arthritis.Client
has recent history of hip fracture surgery less than 3 months
ago.Medications: cefazolin , hydrocodone, vitamins, asthma
medicationAllergies, No Known Drug Allergies (NKDA)
◉ Based on the nurse's assessment which cues support the decision to
provide intervention for the client's pain as the first priority? (Select
all that apply. One, some, or all options may be correct.)
a. Blood pressure
b. Client's reported pain level of 7/10.
c. History of rheumatoid arthritis.
d. Recent hip surgery within the last 3 months.
e. Examination of the client's right lower extremity.. Answer: a. Blood
pressure.
The autonomic nervous system responds to pain through sympathetic
nervous system responses like elevated blood pressure, pulse, and
respiratory rate.Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L.,
Harding, M. (2017). Medical-Surgical Nursing: assessment and
management of clinical problems. (10th ed.), St. Louis, MO., Elsevier,
Inc. p. 107.
b. Client's reported pain level of 7/10.
Pain is an individual experience and it is what the client says it
is.Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., Harding, M.
(2017). Medical-Surgical Nursing: assessment and management of
clinical problems. (10th ed.), St. Louis, MO., Elsevier, Inc. p. 107.
, c. History of rheumatoid arthritis.
Rheumatoid arthritis causes chronic pain related to swelling and
tenderness of joints.Lewis, S., Dirksen, S., Heitkemper, M., Bucher,
L., Harding, M. (2017). Medical-Surgical Nursing: assessment and
management of clinical problems. (10th ed.), St. Louis, MO., Elsevier,
Inc. p. 107
d. Recent hip surgery within the last 3 months.
Nursing interventions for clients with recent hip fracture surgery are
geared toward relieving pain in order to promote mobility and prevent
complications. Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L.,
Harding, M. (2017). Medical-Surgical Nursing: assessment and
management of clinical problems. (10th ed.), St. Louis, MO., Elsevier,
Inc. p. 107.
e. Examination of the client's right lower extremity.
Warmth, redness, tenderness and other factors at the site may be
causing the pain.
◉ The client is describing the pain in her right leg as severe and
concentrated in her foot and ankle. The nurse receives a prescription
from the HCP for hydrocodone bitartrate and acetaminophen 5/325
two tabs PO prior to the client's exam. Before initiating the treatment,
it is most important for the nurse to implement which interventions?
(Select all that apply. One, some, or all options may be correct.)
a. Perform a focused assessment on the lower right extremity.
ANSWERS CORRECT ANSWERS AND
SOLUTIONS
◉ Meet the Client (scenario). Answer: The client is recovering from
hip fracture surgery less than 3 months ago. She has a history of
rheumatoid arthritis and stated that she fell while mopping her kitchen
floor fracturing her right hip and required surgery. The client received
prophylactic enoxaparin injections while hospitalized and continued
to self-administer the injections upon discharge home as prescribed.
The last injection was one month ago. The client reports that her right
leg began swelling a few days ago and is now quite painful at a pain
level 7/10. Her spouse drove her to the Peripheral Vascular Clinic to
have her leg examined. The health care provider (HCP) at the clinic
performed diagnostics and suspects a deep vein thrombosis (DVT).
He prescribed a transfer for the client to be admitted to the inpatient
setting for further diagnostics and treatment. The client states she
feels anxious about being admitted to the hospital.
◉ Assessment. Answer: Vital signs: blood pressure 160/82 mmHg,
heart rate 80 beats/min., temperature 100o F (37.78o C), respiratory
rate 16 breaths/min., oxygen saturation 98% on room air5 ft. 2 in
(157.48 cm)/ weighs 165 lbs. (84.09 kg)Breath sounds clear upon
auscultation with bilaterally equal expansion.Respirations regular
with no dyspnea or cough.Right lower extremity: edematous,
erythema, tenderness, warmthClient states pain level is 7/10.Pedal
pulses normal 2+ bilaterally with capillary refill greater than 3.Client
reports that her leg has been painful since the previous evening.Client
,reports severe pain in her foot and ankle.Client has a history of taking
oral contraceptives.Client has a history of rheumatoid arthritis.Client
has recent history of hip fracture surgery less than 3 months
ago.Medications: cefazolin , hydrocodone, vitamins, asthma
medicationAllergies, No Known Drug Allergies (NKDA)
◉ Based on the nurse's assessment which cues support the decision to
provide intervention for the client's pain as the first priority? (Select
all that apply. One, some, or all options may be correct.)
a. Blood pressure
b. Client's reported pain level of 7/10.
c. History of rheumatoid arthritis.
d. Recent hip surgery within the last 3 months.
e. Examination of the client's right lower extremity.. Answer: a. Blood
pressure.
The autonomic nervous system responds to pain through sympathetic
nervous system responses like elevated blood pressure, pulse, and
respiratory rate.Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L.,
Harding, M. (2017). Medical-Surgical Nursing: assessment and
management of clinical problems. (10th ed.), St. Louis, MO., Elsevier,
Inc. p. 107.
b. Client's reported pain level of 7/10.
Pain is an individual experience and it is what the client says it
is.Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., Harding, M.
(2017). Medical-Surgical Nursing: assessment and management of
clinical problems. (10th ed.), St. Louis, MO., Elsevier, Inc. p. 107.
, c. History of rheumatoid arthritis.
Rheumatoid arthritis causes chronic pain related to swelling and
tenderness of joints.Lewis, S., Dirksen, S., Heitkemper, M., Bucher,
L., Harding, M. (2017). Medical-Surgical Nursing: assessment and
management of clinical problems. (10th ed.), St. Louis, MO., Elsevier,
Inc. p. 107
d. Recent hip surgery within the last 3 months.
Nursing interventions for clients with recent hip fracture surgery are
geared toward relieving pain in order to promote mobility and prevent
complications. Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L.,
Harding, M. (2017). Medical-Surgical Nursing: assessment and
management of clinical problems. (10th ed.), St. Louis, MO., Elsevier,
Inc. p. 107.
e. Examination of the client's right lower extremity.
Warmth, redness, tenderness and other factors at the site may be
causing the pain.
◉ The client is describing the pain in her right leg as severe and
concentrated in her foot and ankle. The nurse receives a prescription
from the HCP for hydrocodone bitartrate and acetaminophen 5/325
two tabs PO prior to the client's exam. Before initiating the treatment,
it is most important for the nurse to implement which interventions?
(Select all that apply. One, some, or all options may be correct.)
a. Perform a focused assessment on the lower right extremity.
