AH3 Exam 3 – DVT & Stroke NCLEX Review | 2025/2026
Updated Study Guide & Practice Questions | 100% Pass
Guarantee
The nurse is completing an assessment on a newly admitted client. What assessment
finding would suggest to the nurse that a client is experiencing a deep venous
thrombosis?
A) Shortness of breath after activity
B) Two-plus palpable pedal pulses
C) Swelling in one leg with pitting edema
D) Bilateral calf tenderness after walking up a flight of stairs - correct answerC) Swelling
in one leg with pitting edema
Rationale:
Manifestations of deep venous thrombosis include swelling in one leg with pitting edema
because the clot is obstructing the venous return from the leg. Bilateral calf tenderness
may be a normal reaction to the exercise of climbing stairs. Shortness of breath that
subsides after activity and two-plus palpable pulses are not manifestations of deep
venous thrombosis.
The nurse is planning care for a group of clients. Which client should the nurse realize
has the greatest risk for developing deep venous thrombosis?
A) The client recovering from laparoscopic gallbladder surgery
B) The client admitted with new-onset type II diabetes mellitus
C) The client admitted with community-acquired pneumonia
D) The client recovering from knee replacement surgery - correct answerD) The client
recovering from knee replacement surgery
Rationale:
Up to 60% of clients recovering from total knee replacement surgery can develop a
deep venous thrombosis. This is because of the procedure and prolonged immobility
after surgery. The client admitted with new-onset type II diabetes mellitus, the client
admitted with community-acquired pneumonia, and the client recovering from
laparoscopic gallbladder surgery would be at a lower risk for deep venous thrombosis
because prolonged immobility will not occur.
A client recovering from a cesarean section is afebrile but is experiencing tenderness,
localized heat, and redness of the left leg. What would be the best intervention for the
client at this time?
A) Encourage to ambulate freely.
,B) Provide aspirin 650 mg by mouth.
C) Place on bed rest.
D) Provide Methergine IM. - correct answerC) Place on bed rest.
Rationale:
These symptoms indicate the presence of superficial thrombophlebitis. The treatment
involves bed rest and elevation of the affected limb, analgesics, and the use of elastic
support hose. Ambulation would increase the inflammation. Aspirin does have
anticoagulant properties but may not be the medication of choice at this time.
Methergine is given only for postpartum hemorrhage and would cause vasoconstriction
of an already inflamed vessel.
The nurse is planning care for a client with deep venous thrombosis. Which nursing
diagnosis would be a priority for this client?
A) Risk for Infection related to obstructed venous return
B) Excess Fluid Volume related to tissue edema
C) Ineffective Tissue Perfusion related to obstructed venous return
D) Disturbed Sleep Pattern related to tissue hypoxia - correct answerC) Ineffective
Tissue Perfusion related to obstructed venous return
Rationale:
Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis
because it identifies the underlying cause. Excess Fluid Volume related to tissue edema
and Disturbed Sleep Pattern related to tissue hypoxia are incorrect because they do not
identify the underlying cause. Risk for Infection related to obstructed venous return
would be a priority if complications of infection were present, however this is not the
case.
The nurse is providing discharge instructions to a postpartum client recovering from
deep venous thrombosis. What should these instructions include? Select all that apply.
A) Avoid crossing the legs.
B) Avoid long car trips.
C) Avoid prolonged standing or sitting.
D) Take frequent walks.
E) Take a daily aspirin dose of 650 mg. - correct answerA) Avoid crossing the legs.
C) Avoid prolonged standing or sitting.
D) Take frequent walks.
Rationale:
The client should be instructed to avoid crossing the legs because it increases pressure
on the veins of the lower extremities. The client should be instructed also to avoid
prolonged standing or sitting, which contributes to venous stasis. The client should also
be instructed to take frequent walks to promote venous return. The client should not be
instructed to take a daily aspirin, because it will increase anticoagulant activity and
,could interact with other medication prescribed for the treatment of the deep venous
thrombosis. The client does not need to be instructed to avoid long car trips but rather to
take frequent breaks during long car trips.
A client diagnosed with a deep vein thrombosis is receiving intravenous heparin. What
does the nurse identify as the priority outcome for this client?
A) The client will not disturb the intravenous infusion.
B) The client will comply with dietary restrictions.
C) The client will not experience bleeding.
D) The client will keep the right leg elevated on two pillows. - correct answerC) The
client will not experience bleeding.
Rationale:
An absence of bleeding is a priority outcome for any client receiving anticoagulant
therapy. Disturbing the intravenous line could relate to bleeding, but this does not
directly correlate with heparin. Dietary restrictions are important but not as high a priority
as an absence of bleeding. Elevation of the affected extremity is important but not as
high a priority as an absence of bleeding.
A client receiving heparin therapy for deep venous thrombosis complains of severe
chest pain and shortness of breath. Suspecting a pulmonary embolism, what action
should the nurse perform first?
A) Assess pulse, respirations, and blood pressure.
B) Apply oxygen and elevate the head of the bed.
C) Reassure the client and notify family members.
D) Increase the rate of heparin infusion. - correct answerB) Apply oxygen and elevate
the head of the bed.
Rationale:
Applying oxygen and elevating the head of the bed will promote ventilation and gas
exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation.
Increasing the rate of heparin infusion cannot be done by the nurse without an order
from a healthcare provider. Reassuring the client and notifying family members are not
priorities, although these measures can decrease the client's anxiety; the priority is to
begin oxygen therapy and elevate the head of the bed to increase oxygenation to the
tissues. Assessing pulse, respiration, and blood pressure will be performed following the
initiation of oxygen therapy and bed elevation.
A client being treated for a deep venous thrombosis is experiencing pain. What can the
nurse do to assist this client? Select all that apply.
A) Apply an egg-crate mattress on the bed.
B) Maintain bed rest as ordered.
C) Apply warm moist heat to the area four times a day.
, D) Encourage position changes every 2 hours.
E) Measure calf and thigh diameter daily. - correct answerB) Maintain bed rest as
ordered.
C) Apply warm moist heat to the area four times a day.
E) Measure calf and thigh diameter daily.
Rationale:
Interventions to address pain include applying warm moist heat to the area four times a
day, maintaining bed rest as ordered, and measuring calf and thigh diameter daily.
Applying an egg-crate mattress on the bed and encouraging position changes every 2
hours would be appropriate for the client experiencing Ineffective Tissue Perfusion.
A client admitted with chronic venous insufficiency has an infected wound of the left
lower extremity. What will the nurse find when assessing this wound? Select all that
apply.
A) Pulses absent in the extremity with the wound
B) Wound that is pink with skin warm
C) Ulceration that is pale in color
D) Skin surrounding ulcer that is cool to the touch
E) Surrounding skin brown in color - correct answerB) Wound that is pink with skin
warm
E) Surrounding skin brown in color
Rationale:
Manifestations of a venous status ulcer would be a pink wound with warm skin and
areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and
absent pulses is manifestations of arterial ulcers.
A client diagnosed with peripheral vascular disease is obese, has a 30-year history of
cigarette smoking, and works as a contractor. What should the nurse instruct the client
about the diagnosis?
A) Nicotine is a vasoconstrictor.
B) Obesity is a factor in cardiovascular disease but not peripheral vascular disease.
C) Nicotine primarily affects coronary arteries and the lungs.
D) The client's occupation is a major risk factor. - correct answerA) Nicotine is a
vasoconstrictor.
Rationale:
The vasoconstrictive properties of nicotine will worsen the client's peripheral vascular
disease (PVD) by further decreasing peripheral blood flow. One of the most important
parts of treatment is the cessation of cigarette smoking. The client's occupation is not a
risk factor related to PVD. Obesity is a risk factor for both cardiovascular as well as
PVD; however, the nurse should focus on smoking cessation as a first priority with this
client.
Updated Study Guide & Practice Questions | 100% Pass
Guarantee
The nurse is completing an assessment on a newly admitted client. What assessment
finding would suggest to the nurse that a client is experiencing a deep venous
thrombosis?
A) Shortness of breath after activity
B) Two-plus palpable pedal pulses
C) Swelling in one leg with pitting edema
D) Bilateral calf tenderness after walking up a flight of stairs - correct answerC) Swelling
in one leg with pitting edema
Rationale:
Manifestations of deep venous thrombosis include swelling in one leg with pitting edema
because the clot is obstructing the venous return from the leg. Bilateral calf tenderness
may be a normal reaction to the exercise of climbing stairs. Shortness of breath that
subsides after activity and two-plus palpable pulses are not manifestations of deep
venous thrombosis.
The nurse is planning care for a group of clients. Which client should the nurse realize
has the greatest risk for developing deep venous thrombosis?
A) The client recovering from laparoscopic gallbladder surgery
B) The client admitted with new-onset type II diabetes mellitus
C) The client admitted with community-acquired pneumonia
D) The client recovering from knee replacement surgery - correct answerD) The client
recovering from knee replacement surgery
Rationale:
Up to 60% of clients recovering from total knee replacement surgery can develop a
deep venous thrombosis. This is because of the procedure and prolonged immobility
after surgery. The client admitted with new-onset type II diabetes mellitus, the client
admitted with community-acquired pneumonia, and the client recovering from
laparoscopic gallbladder surgery would be at a lower risk for deep venous thrombosis
because prolonged immobility will not occur.
A client recovering from a cesarean section is afebrile but is experiencing tenderness,
localized heat, and redness of the left leg. What would be the best intervention for the
client at this time?
A) Encourage to ambulate freely.
,B) Provide aspirin 650 mg by mouth.
C) Place on bed rest.
D) Provide Methergine IM. - correct answerC) Place on bed rest.
Rationale:
These symptoms indicate the presence of superficial thrombophlebitis. The treatment
involves bed rest and elevation of the affected limb, analgesics, and the use of elastic
support hose. Ambulation would increase the inflammation. Aspirin does have
anticoagulant properties but may not be the medication of choice at this time.
Methergine is given only for postpartum hemorrhage and would cause vasoconstriction
of an already inflamed vessel.
The nurse is planning care for a client with deep venous thrombosis. Which nursing
diagnosis would be a priority for this client?
A) Risk for Infection related to obstructed venous return
B) Excess Fluid Volume related to tissue edema
C) Ineffective Tissue Perfusion related to obstructed venous return
D) Disturbed Sleep Pattern related to tissue hypoxia - correct answerC) Ineffective
Tissue Perfusion related to obstructed venous return
Rationale:
Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis
because it identifies the underlying cause. Excess Fluid Volume related to tissue edema
and Disturbed Sleep Pattern related to tissue hypoxia are incorrect because they do not
identify the underlying cause. Risk for Infection related to obstructed venous return
would be a priority if complications of infection were present, however this is not the
case.
The nurse is providing discharge instructions to a postpartum client recovering from
deep venous thrombosis. What should these instructions include? Select all that apply.
A) Avoid crossing the legs.
B) Avoid long car trips.
C) Avoid prolonged standing or sitting.
D) Take frequent walks.
E) Take a daily aspirin dose of 650 mg. - correct answerA) Avoid crossing the legs.
C) Avoid prolonged standing or sitting.
D) Take frequent walks.
Rationale:
The client should be instructed to avoid crossing the legs because it increases pressure
on the veins of the lower extremities. The client should be instructed also to avoid
prolonged standing or sitting, which contributes to venous stasis. The client should also
be instructed to take frequent walks to promote venous return. The client should not be
instructed to take a daily aspirin, because it will increase anticoagulant activity and
,could interact with other medication prescribed for the treatment of the deep venous
thrombosis. The client does not need to be instructed to avoid long car trips but rather to
take frequent breaks during long car trips.
A client diagnosed with a deep vein thrombosis is receiving intravenous heparin. What
does the nurse identify as the priority outcome for this client?
A) The client will not disturb the intravenous infusion.
B) The client will comply with dietary restrictions.
C) The client will not experience bleeding.
D) The client will keep the right leg elevated on two pillows. - correct answerC) The
client will not experience bleeding.
Rationale:
An absence of bleeding is a priority outcome for any client receiving anticoagulant
therapy. Disturbing the intravenous line could relate to bleeding, but this does not
directly correlate with heparin. Dietary restrictions are important but not as high a priority
as an absence of bleeding. Elevation of the affected extremity is important but not as
high a priority as an absence of bleeding.
A client receiving heparin therapy for deep venous thrombosis complains of severe
chest pain and shortness of breath. Suspecting a pulmonary embolism, what action
should the nurse perform first?
A) Assess pulse, respirations, and blood pressure.
B) Apply oxygen and elevate the head of the bed.
C) Reassure the client and notify family members.
D) Increase the rate of heparin infusion. - correct answerB) Apply oxygen and elevate
the head of the bed.
Rationale:
Applying oxygen and elevating the head of the bed will promote ventilation and gas
exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation.
Increasing the rate of heparin infusion cannot be done by the nurse without an order
from a healthcare provider. Reassuring the client and notifying family members are not
priorities, although these measures can decrease the client's anxiety; the priority is to
begin oxygen therapy and elevate the head of the bed to increase oxygenation to the
tissues. Assessing pulse, respiration, and blood pressure will be performed following the
initiation of oxygen therapy and bed elevation.
A client being treated for a deep venous thrombosis is experiencing pain. What can the
nurse do to assist this client? Select all that apply.
A) Apply an egg-crate mattress on the bed.
B) Maintain bed rest as ordered.
C) Apply warm moist heat to the area four times a day.
, D) Encourage position changes every 2 hours.
E) Measure calf and thigh diameter daily. - correct answerB) Maintain bed rest as
ordered.
C) Apply warm moist heat to the area four times a day.
E) Measure calf and thigh diameter daily.
Rationale:
Interventions to address pain include applying warm moist heat to the area four times a
day, maintaining bed rest as ordered, and measuring calf and thigh diameter daily.
Applying an egg-crate mattress on the bed and encouraging position changes every 2
hours would be appropriate for the client experiencing Ineffective Tissue Perfusion.
A client admitted with chronic venous insufficiency has an infected wound of the left
lower extremity. What will the nurse find when assessing this wound? Select all that
apply.
A) Pulses absent in the extremity with the wound
B) Wound that is pink with skin warm
C) Ulceration that is pale in color
D) Skin surrounding ulcer that is cool to the touch
E) Surrounding skin brown in color - correct answerB) Wound that is pink with skin
warm
E) Surrounding skin brown in color
Rationale:
Manifestations of a venous status ulcer would be a pink wound with warm skin and
areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and
absent pulses is manifestations of arterial ulcers.
A client diagnosed with peripheral vascular disease is obese, has a 30-year history of
cigarette smoking, and works as a contractor. What should the nurse instruct the client
about the diagnosis?
A) Nicotine is a vasoconstrictor.
B) Obesity is a factor in cardiovascular disease but not peripheral vascular disease.
C) Nicotine primarily affects coronary arteries and the lungs.
D) The client's occupation is a major risk factor. - correct answerA) Nicotine is a
vasoconstrictor.
Rationale:
The vasoconstrictive properties of nicotine will worsen the client's peripheral vascular
disease (PVD) by further decreasing peripheral blood flow. One of the most important
parts of treatment is the cessation of cigarette smoking. The client's occupation is not a
risk factor related to PVD. Obesity is a risk factor for both cardiovascular as well as
PVD; however, the nurse should focus on smoking cessation as a first priority with this
client.
