NCLEX Deep Vein Thrombosis (DVT) EXAM
Rationale: Risk factors for the develop-
While conducting an assessment, the ment of a DVT include cancer, atrial fi
nurse concludes that a client is at risk for lation, and myocardial infarction. Use of
developing a deep venous thrombosis. over-the-counter medication for arthritis
Which assessment finding led the nurse and having controlled type 2 diabetes
to this conclusion? (Select all that appm lye.)llitus are not risk factors for the devel-
opment of this health problem.
The nurse is reviewing the personal and Rationale: Hormone therapy, lung ca
cer, and pregnancy are all risk factors for
medical history of several clients. Which
the development of DVT. Hypercholes-
finding indicates that a client is at risk
terolemia and diabetes mellitus are risk
for the development of a deep venous
factors for peripheral vascular disease,
thrombosis? (Select all that apply.)
not DVT.
Rationale: Pulmonary embolism is a
complication of DVT. Assessing the
client's respiratory status, including aus
cultating bilateral breath sounds, is ap-
propriate. The client's airway and breath
The nurse is caring for a client diagnosed ing take priority. Atrial fibrillation and is-
with a deep venous thrombosis. Which chemic stroke are risk factors for de-
nursing assessment is a priority ? velopment of DVT. Assessing level of
consciousness and performing a stroke
scale assessment are appropriate to as-
sess for ischemic stroke. Obtaining EKG
rhythm and rate is appropriate to assess
for atrial fibrillation.
Rationale: Signs and symptoms of DVT
include cyanosis, dull aching pain when
The nurse should assess which client for walking, edema greater in one leg, and
possible deep venous thrombosis? (Sec-apillary refill greater in one leg. DVT is
lect all that apply.) often asymptomatic. The client who has
had surgery is at risk for DVT and should
be assessed.
The nurse is giving a presentation re- Rationale: Virchow's triad is named for
garding the pathologic factors that may the three pathologic factors associated
lead to the formation of a thrombus. with the formation of a thrombus: circu
latory stasis, vascular damage, and
1/5
, NCLEX Deep Vein Thrombosis (DVT) EXAM
percoagulability. An inactive lifestyle (no
Which participant statement indicates a
an active lifestyle) can lead to circulator
need for further teaching?
stasis and thrombus formation
Rationale: Atrial fibrillation is a risk factor
for deep venous thrombosis (DVT). El-
The nurse is caring for a client admitted evating the feet and keeping the knees
with new onset atrial fibrillation. Which slightly flexed will prevent venous stasis
intervention should be included in the and decrease the risk for DVT. Edema,
plan of care? (Select all that apply.) aching pain, warmth, cyanosis, and
derness, especially in one lower extrem
ity, are signs of DVT.
Rationale: Elevating the foot of the bed
and keeping the knees slightly flexed will
The nurse is caring for a client who had promote venous return and decrease the
a total hip replacement 8 hours ago. The risk of DVT. Early mobilization, prophy-
nurse should question which order? lactic anticoagulant therapy, compres-
sion stockings, and pneumatic compres
sion devices are used to prevent DVT.
Rationale: Estrogen in contraceptives
Adolescent and young adult women are or in hormone replacement therapy in-
at a greater risk for thrombosis. Which creases the risk for thrombosis. Prematu-
accurately explains one reason for the rity at birth, increased risk of sepsis,
increased blood volume and pressure do
increased risk?
not explain why women have a greater
risk for thrombosis.
Rationale: Heparin therapy is consid-
ered safe during pregnancy because he-
parin does not cross the placenta. War-
farin does cross the placenta and may
A client at 27 weeks' gestation is di-
cause congenital malformations; there-
agnosed with deep venous thrombosis.
fore, it is contraindicated during pregnan-
Which collaborative therapy should the
cy. An emergency cesarean section is
nurse anticipate?
not indicated with the information pro-
vided. Even if the client is on heparin
therapy, there is not an increased risk of
hemorrhage after delivery.
2/5
Rationale: Risk factors for the develop-
While conducting an assessment, the ment of a DVT include cancer, atrial fi
nurse concludes that a client is at risk for lation, and myocardial infarction. Use of
developing a deep venous thrombosis. over-the-counter medication for arthritis
Which assessment finding led the nurse and having controlled type 2 diabetes
to this conclusion? (Select all that appm lye.)llitus are not risk factors for the devel-
opment of this health problem.
The nurse is reviewing the personal and Rationale: Hormone therapy, lung ca
cer, and pregnancy are all risk factors for
medical history of several clients. Which
the development of DVT. Hypercholes-
finding indicates that a client is at risk
terolemia and diabetes mellitus are risk
for the development of a deep venous
factors for peripheral vascular disease,
thrombosis? (Select all that apply.)
not DVT.
Rationale: Pulmonary embolism is a
complication of DVT. Assessing the
client's respiratory status, including aus
cultating bilateral breath sounds, is ap-
propriate. The client's airway and breath
The nurse is caring for a client diagnosed ing take priority. Atrial fibrillation and is-
with a deep venous thrombosis. Which chemic stroke are risk factors for de-
nursing assessment is a priority ? velopment of DVT. Assessing level of
consciousness and performing a stroke
scale assessment are appropriate to as-
sess for ischemic stroke. Obtaining EKG
rhythm and rate is appropriate to assess
for atrial fibrillation.
Rationale: Signs and symptoms of DVT
include cyanosis, dull aching pain when
The nurse should assess which client for walking, edema greater in one leg, and
possible deep venous thrombosis? (Sec-apillary refill greater in one leg. DVT is
lect all that apply.) often asymptomatic. The client who has
had surgery is at risk for DVT and should
be assessed.
The nurse is giving a presentation re- Rationale: Virchow's triad is named for
garding the pathologic factors that may the three pathologic factors associated
lead to the formation of a thrombus. with the formation of a thrombus: circu
latory stasis, vascular damage, and
1/5
, NCLEX Deep Vein Thrombosis (DVT) EXAM
percoagulability. An inactive lifestyle (no
Which participant statement indicates a
an active lifestyle) can lead to circulator
need for further teaching?
stasis and thrombus formation
Rationale: Atrial fibrillation is a risk factor
for deep venous thrombosis (DVT). El-
The nurse is caring for a client admitted evating the feet and keeping the knees
with new onset atrial fibrillation. Which slightly flexed will prevent venous stasis
intervention should be included in the and decrease the risk for DVT. Edema,
plan of care? (Select all that apply.) aching pain, warmth, cyanosis, and
derness, especially in one lower extrem
ity, are signs of DVT.
Rationale: Elevating the foot of the bed
and keeping the knees slightly flexed will
The nurse is caring for a client who had promote venous return and decrease the
a total hip replacement 8 hours ago. The risk of DVT. Early mobilization, prophy-
nurse should question which order? lactic anticoagulant therapy, compres-
sion stockings, and pneumatic compres
sion devices are used to prevent DVT.
Rationale: Estrogen in contraceptives
Adolescent and young adult women are or in hormone replacement therapy in-
at a greater risk for thrombosis. Which creases the risk for thrombosis. Prematu-
accurately explains one reason for the rity at birth, increased risk of sepsis,
increased blood volume and pressure do
increased risk?
not explain why women have a greater
risk for thrombosis.
Rationale: Heparin therapy is consid-
ered safe during pregnancy because he-
parin does not cross the placenta. War-
farin does cross the placenta and may
A client at 27 weeks' gestation is di-
cause congenital malformations; there-
agnosed with deep venous thrombosis.
fore, it is contraindicated during pregnan-
Which collaborative therapy should the
cy. An emergency cesarean section is
nurse anticipate?
not indicated with the information pro-
vided. Even if the client is on heparin
therapy, there is not an increased risk of
hemorrhage after delivery.
2/5
