DVT Exam Solved

DVT Exam Solved Following a total joint replacement, which complication has the greatest likelihood of occurring? a) displacement of the new joint b) deep vein thrombosis (DVT) c) wound evisceration d) polyuria - Answer- deep vein thrombosis (DVT) Correct Explanation: DVT is a complication of total joint replacement and may occur during hospitalization or develop later when the client is home. Clients who are obese or have previous history of a deep vein thrombosis or pulmonary embolism are at high risk. Immobility produces venous stasis, increasing the client's chance to develop a venous thromboembolism. Signs of a DVT include unilateral calf tenderness, warmth, redness, and edema (increased calf circumference). Findings should be reported promptly to the health care provider (HCP) for definitive evaluation and therapy. Polyuria may be indicative of diabetes mellitus. Displacement of the new joint is unlikely. Wound evisceration is more likely to occur after abdominal surgeries. Knee-high sequential compression devices have been prescribed for a newly admitted client. The client reports new pain localized in the right calf area that is noted to be slightly reddened and warm to touch upon initial assessment. What should the nurse do first? a) Massage the area of discomfort before applying the compression devices. b) Leave the compression devices off, and contact the health care provider (HCP) to report the assessment findings. c) Leave the compression devices off, and report the assessment findings to the oncoming shift. d) Offer analgesics as ordered, and apply the compression devices. - Answer- Leave the compression devices off, and contact the health care provider (HCP) to report the assessment findings. Correct Explanation: Localized pain, tenderness, redness, and warmth may be symptoms of deep vein thrombosis (DVT), information the nurse should report to the HCP; the compression devices should not be applied until further evaluation is completed as intermittent compression may dislodge a thrombus. Massaging the area may dislodge a thrombus and is not recommended. The nurse may offer PRN analgesics if the client requires pain management, but the compression devices should not be applied until further evaluation is completed. Diagnosis and treatment of DVT should be discussed with the HCP as soon as possible; the nurse should not wait until the next shift to report findings as a DVT can become life threatening if a thrombus travels to the lung and becomes a pulmonary embolus Which of these measures would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client? a) Placing graduated compression stockings on the client. b) Encouraging the client to elevate the head of bed. c) Teaching the client about the use of incentive spirometer. d) Elevating bilateral legs when lying in the bed. - Answer- Placing graduated compression stockings on the client. Correct Explanation: Use of graduated compression stockings and/or pneumatic compression devices on the client will help with prevention of DVT, which is a risk for clients after surgery. Elevating the client?s legs will passively improve venous return but not prevent DVT if a client is not up and walking to more actively promote venous return. Elevating the head of bed and using the incentive spirometer help prevent postoperative complications of atelectasis or pneumonia Which of the following nursing actions would help prevent deep vein thrombosis in a patient who has had an orthopedic surgery? a) Apply cold packs b) Instruct about using patient-controlled analgesia, if prescribed c) Apply antiembolism stockings d) Instruct about exercise, as prescribed - Answer- Apply antiembolism stockings Correct Explanation: Applying antiembolism stockings helps prevent deep vein thrombosis (DVT) in a patient who is immobilized due to orthopedic surgery. Regular administration of analgesics controls and prevents escalation of pain while ROM exercises help in maintaining muscle strength and tone and prevent contractions. On the other hand, cold packs are applied to help reduce swelling and it does not prevent deep vein thrombosis. A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? a) Ineffective peripheral tissue perfusion related to venous congestion b) Excess fluid volume related to peripheral vascular disease c) Impaired gas exchange related to increased blood flow d) Risk for injury related to edema - Answer- Ineffective peripheral tissue perfusion related to venous congestion Correct Explanation: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion. A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following? a) Tense and relax muscles in lower extremities. b) Consume majority of fluid intake prior to bed. c) Begin estrogen replacement. d) Wear tight-fitting clothing. - Answer- Tense and relax muscles in lower extremities. Correct Explanation: Clients are encouraged to perform passive or active exercises, as tolerated, to prevent the development of a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. The nurse should first: a) perform range of motion exercises in the involved leg. b) administer morphine sulfate 2 mg IV. c) call the health care provider (HCP). d) assess the oxygen saturation. - Answer- assess the oxygen saturation. Correct Explanation: A client with deep vein thrombosis (DVT) is at high risk for a pulmonary embolism from an embolus traveling to the lung. Sudden onset of symptoms and worsening of chest pain with a deep breath suggest a pulmonary embolism. The nurse assesses the client and obtains oxygen saturation levels prior to calling the HCP and administering morphine. Range of motion is a preventive measure for DVT and is not appropriate that this time A client newly diagnosed with deep vein thrombosis (DVT) of the left lower left extremity is on bed rest. The nurse should instruct the unlicensed assistive personnel (UAP) providing routine morning care for the client to: a) massage the leg and foot with lotion. b) check that the legs are in a low, dependent position. c) ensure that the lower extremity is elevated. d) place one or two pillows under the client's left knee. - Answer- ensure that the lower extremity is elevated. Correct Explanation: DVT causes edema; therefore, the UAP should elevate the extremity to promote venous return. Dependent positioning is appropriate for a client with arterial insufficiency. Placing a pillow under the knee would position the foot in a low position, and pressure behind the knee may obstruct venous flow. Massaging the extremity could dislodge the thrombus