DVT and PE Exam Graded A+
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1. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing
assessment indicates that an important outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors: ANS: B
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred.
The other assessments are also positive, but not as important.
2. A client has a deep vein thrombosis (DVT). What comfort measure does the
nurse delegate to the assistive personnel (AP)?
a. Ambulate the client.
b. Apply a warm moist pack.
c. Massage the client's leg.
d. Provide an ice pack.: ANS: B
Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is
contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.
3. A nurse is assessing an obese client in the clinic for follow-up after an episode
of deep vein thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit.
What action by the nurse is best?
a. Ask if the weight loss was intended.
b. Encourage a high-protein, high-fiber diet.
c. Measure for new compression stockings.
d. Review a 3-day food recall diary.: ANS: C
Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client would
be remeasured and new stockings ordered if needed. The other options are appropriate, but not the most important.
4. A client has been diagnosed with a deep vein thrombosis and is to be dis-
charged on warfarin. The client is adamant about refusing the drug because
"it's dangerous." What action by the nurse is best?
a. Assess the reason behind the client's fear.
b. Remind the client about laboratory monitoring.
c. Tell the client that drugs are safer today than before.
d. Warn the client about consequences of noncompliance.: ANS: A
1/7
, DVT and PE Exam Graded A+
Study online at https://quizlet.com/_i3kvvj
The first step is to assess the reason behind the client's fear, which may be related to the experience of someone the
client knows who took warfarin or misinformation. If the nurse cannot address the specific rationale, teaching will likely
be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe.
General statements like "drugs are safer today" do not address the root cause of the problem. Warning the client about
possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.
5. A client has been bedridden for several days after major abdominal surgery.
What action does the nurse delegate to the assistive personnel (AP) for deep
vein thrombosis (DVT) prevention? (Select all that apply.)
a. Apply compression stockings.
b. Assist with ambulation.
c. Encourage coughing and deep breathing.
d. Offer fluids frequently.
e. Teach leg exercises.: ANS: A,B,D
The AP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The
AP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a
nursing function.
6. A nurse is caring for a client on IV infusion of heparin. What actions does this
nurse include in the client's plan of care? (Select all that apply.)
a. Assess the client for bleeding.
b. Monitor the daily activated partial thromboplastin time (aPTT) results.
c. Stop the IV for aPTT above baseline.
d. Use an IV pump for the infusion.
e. Weigh the client daily on the same scale.: ANS: A,B,D
Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for
heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2.5 times normal in order to demonstrate that the
heparin is therapeutic. Weighing the client is not related.
7. A client is being discharged on warfarin therapy. What discharge instruction
is the nurse required to provide? (Select all that apply.)
a. Dietary restrictions
b. Driving restrictions
c. Follow-up laboratory monitoring
d. Possible drug-drug interactions
2/7
Study online at https://quizlet.com/_i3kvvj
1. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing
assessment indicates that an important outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors: ANS: B
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred.
The other assessments are also positive, but not as important.
2. A client has a deep vein thrombosis (DVT). What comfort measure does the
nurse delegate to the assistive personnel (AP)?
a. Ambulate the client.
b. Apply a warm moist pack.
c. Massage the client's leg.
d. Provide an ice pack.: ANS: B
Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is
contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.
3. A nurse is assessing an obese client in the clinic for follow-up after an episode
of deep vein thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit.
What action by the nurse is best?
a. Ask if the weight loss was intended.
b. Encourage a high-protein, high-fiber diet.
c. Measure for new compression stockings.
d. Review a 3-day food recall diary.: ANS: C
Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client would
be remeasured and new stockings ordered if needed. The other options are appropriate, but not the most important.
4. A client has been diagnosed with a deep vein thrombosis and is to be dis-
charged on warfarin. The client is adamant about refusing the drug because
"it's dangerous." What action by the nurse is best?
a. Assess the reason behind the client's fear.
b. Remind the client about laboratory monitoring.
c. Tell the client that drugs are safer today than before.
d. Warn the client about consequences of noncompliance.: ANS: A
1/7
, DVT and PE Exam Graded A+
Study online at https://quizlet.com/_i3kvvj
The first step is to assess the reason behind the client's fear, which may be related to the experience of someone the
client knows who took warfarin or misinformation. If the nurse cannot address the specific rationale, teaching will likely
be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe.
General statements like "drugs are safer today" do not address the root cause of the problem. Warning the client about
possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.
5. A client has been bedridden for several days after major abdominal surgery.
What action does the nurse delegate to the assistive personnel (AP) for deep
vein thrombosis (DVT) prevention? (Select all that apply.)
a. Apply compression stockings.
b. Assist with ambulation.
c. Encourage coughing and deep breathing.
d. Offer fluids frequently.
e. Teach leg exercises.: ANS: A,B,D
The AP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The
AP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a
nursing function.
6. A nurse is caring for a client on IV infusion of heparin. What actions does this
nurse include in the client's plan of care? (Select all that apply.)
a. Assess the client for bleeding.
b. Monitor the daily activated partial thromboplastin time (aPTT) results.
c. Stop the IV for aPTT above baseline.
d. Use an IV pump for the infusion.
e. Weigh the client daily on the same scale.: ANS: A,B,D
Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for
heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2.5 times normal in order to demonstrate that the
heparin is therapeutic. Weighing the client is not related.
7. A client is being discharged on warfarin therapy. What discharge instruction
is the nurse required to provide? (Select all that apply.)
a. Dietary restrictions
b. Driving restrictions
c. Follow-up laboratory monitoring
d. Possible drug-drug interactions
2/7
