DVT NCLEX
The nurse should assess which client for possible deep venous thrombosis? (Select all that apply.)
Rationale: Signs and symptoms of DVT include cyanosis, dull aching pain when walking, edema greater in one leg, and capillary refill greater in one leg. DVT is often asymptomatic. The client who has had surgery is at risk for DVT and should be assessed.
The nurse is teaching a client with atrial fibrillation about deep venous thrombosis prevention. Which should the nurse instruct the client to avoid? (Select all that apply.)
Rationale: Actions to prevent development of a deep venous thrombosis (DVT) include avoiding prolonged standing or sitting, avoiding crossing the legs, and avoiding tight-fitting or binding garments and stockings. Avoiding extreme exercise does not prevent development of a DVT.
The nurse is caring for a client admitted with new onset atrial fibrillation. Which intervention should be included in the plan of care? (Select all that apply.)
Rationale: Atrial fibrillation is a risk factor for deep venous thrombosis (DVT). Elevating the feet and keeping the knees slightly flexed will prevent venous stasis and decrease the risk for DVT. Edema, aching pain, warmth, cyanosis, and tenderness, especially in one lower extremity, are signs of DVT.
Which nursing diagnosis should be used to guide the care for a client with a deep venous thrombosis (DVT)? (Select all that apply.)
Rationale: Nursing diagnoses that may be appropriate for inclusion in the plan of care for a client with a DVT include Tissue Perfusion, Impaired; Comfort, Impaired; Protection, Ineffective; and Mobility: Physical, Impaired. A DVT does not affect oxygenation. (NANDA-I ©2014)
Which factor places older adults at an increased risk for deep venous thrombosis? (Select all that apply.)
Rationale: Older adults are at an increased risk for deep venous thrombosis due to limited mobility, multiple comorbidities, false positive D-dimers, increased venous stasis, and use of estrogen-containing drugs.
The nurse is preparing to administer an initial dose of heparin. Which should be included in the client's plan of care?
Rationale: Clients with a history of multiple allergies or asthma should be given a test dose of heparin. It is not appropriate to administer heparin in conjunction with aspirin. INR levels are checked for warfarin. Vitamin K reverses the effects of warfarin.
A client presents with tenderness, edema, and erythema of a lower extremity. Which diagnostic test should the nurse anticipate being ordered for this client? (Select all that apply.)
Rationale: Duplex venous ultrasonography, magnetic resonance imaging, and plethysmography are used to diagnose a deep venous thrombosis. Color-flow Doppler ultrasound and magnetic resonance angiography are used to diagnose peripheral vascular disease.
The nurse is caring for a client who had a total hip replacement 8 hours ago. The nurse should question which order?
Rationale: Elevating the foot of the bed and keeping the knees slightly flexed will promote venous return and decrease the risk of DVT. Early mobilization, prophylactic anticoagulant therapy, compression stockings, and pneumatic compression devices are used to prevent DVT.
Adolescent and young adult women are at a greater risk for thrombosis. Which accurately explains one reason for the increased risk?
Rationale: Estrogen in contraceptives or in hormone replacement therapy increases the risk for thrombosis. Prematurity at birth, increased risk of sepsis, and increased blood volume and pressure do not explain why women have a greater risk for thrombosis.
A client at 27 weeks' gestation is diagnosed with deep venous thrombosis. Which collaborative therapy should the nurse anticipate?
Rationale: Heparin therapy is considered safe during pregnancy because heparin does not cross the placenta. Warfarin does cross the placenta and may cause congenital malformations; therefore, it is contraindicated during pregnancy. An emergency cesarean section is not indicated with the information provided. Even if the client is on heparin therapy, there is not an increased risk of hemorrhage after delivery.
The nurse is reviewing the personal and medical history of several clients. Which finding indicates that a client is at risk for the development of a deep venous thrombosis? (Select all that apply.)
Rationale: Hormone therapy, lung cancer, and pregnancy are all risk factors for the development of DVT. Hypercholesterolemia and diabetes mellitus are risk factors for peripheral vascular disease, not DVT.
The nurse is planning care for a client with a deep venous thrombosis of the right calf. Which should the nurse include in this client's plan of care? (Select all that apply.)
Rationale: Interventions that may be appropriate for inclusion in the plan of care for the client with DVT include measuring the calf and thigh diameter of the affected leg every shift; applying warm, moist heat to the affected extremity at least 4 times a day; encouraging range-of-motion exercises; and assisting with deep breathing and coughing. The legs should be elevated, not dependent.
The nurse is caring for a postoperative client who has limited mobility. Which assessment finding should the nurse report as a possible sign of a deep venous thrombosis (DVT)? (Select all that apply.)
Rationale: Manifestations of DVT include calf pain/tightness or dull, aching pain in the affected extremity that gets worse with walking; possible tenderness, swelling, warmth, and erythema along the affected vein; and edema and cyanosis of the affected extremity. Muscle twitching is not a manifestation of DVT.
The nurse is caring for a client diagnosed with a deep venous thrombosis. Which client statement requires an intervention?
Rationale: Mild soaps and lotions should be used to clean the affected leg and foot daily. Alcohol can cause the skin to dry and crack, increasing the risk for infection. Increased fluid and dietary fiber intake should be encouraged because constipation is a common complication of immobility. Frequent position changes while awake will reduce skin breakdown. Elevation of the extremities promotes venous return and reduces peripheral edema. Knee flexion promotes muscle relaxation.
The nurse is creating a plan of care for a client diagnosed with a deep venous thrombosis (DVT). Which intervention should be included in the care plan?
Rationale: Pain is common with DVT and should be assessed and treated regularly. Increased pain should be reported to the healthcare provider. Warm, moist compresses should be used. Skin should be assessed daily. The client will most likely be on bedrest, as increased mobility could cause the thrombus to dislodge and travel to the lungs.
The nurse is caring for a client diagnosed with a deep venous thrombosis. Which nursing assessment is a priority?
Rationale: Pulmonary embolism is a complication of DVT. Assessing the client's respiratory status, including auscultating bilateral breath sounds, is appropriate. The client's airway and breathing take priority. Atrial fibrillation and ischemic stroke are risk factors for development of DVT. Assessing level of consciousness and performing a stroke scale assessment are appropriate to assess for ischemic stroke. Obtaining EKG rhythm and rate is appropriate to assess for atrial fibrillation.
While conducting an assessment, the nurse concludes that a client is at risk for developing a deep venous thrombosis. Which assessment finding led the nurse to this conclusion? (Select all that apply.)
Rationale: Risk factors for the development of a DVT include cancer, atrial fibrillation, and myocardial infarction. Use of over-the-counter medication for arthritis and having controlled type 2 diabetes mellitus are not risk factors for the development of this health problem.
A client with a diagnosis of deep venous thrombosis is being discharged on warfarin therapy. Which statement should the nurse include in discharge teaching? (Select all that apply).
Rationale: Use of a soft-bristle toothbrush will reduce bleeding risk. Regular follow-up and blood tests are necessary to ensure the warfarin therapy remains in therapeutic range. Garlic, green tea, and gingko can increase the risk of bleeding while taking warfarin. Warfarin takes 4-5 days to become effective and should be started before heparin is discontinued. If bleedingoccurs, the dose of warfarin should be skipped and the healthcare provider notified immediately.
The nurse is caring for a client who is scheduled for placement of a filter in the vena cava. The nurse should intervene if the client makes which statement?
Rationale: Vena cava filters will not increase the client's risk of bleeding. Placement of vena cava filters has a low mortality and morbidity and is completed under local anesthesia. The purpose of the filter is to trap thrombi before they enter the lungs and cause pulmonary embolism.
The nurse is giving a presentation regarding the pathologic factors that may lead to the formation of a thrombus. Which participant statement indicates a need for further teaching?
Rationale: Virchow's triad is named for the three pathologic factors associated with the formation of a thrombus: circulatory stasis, vascular damage, and hypercoagulability. An inactive lifestyle (not an active lifestyle) can lead to circulatory stasis and thrombus formation