Mobility and Clotting EAQ

The nurse enters a client's room and finds the client on the floor crying for help. It is obvious to the nurse that the client has sustained a hip fracture. Which action should the nurse take first? A) Administer pain medication. B) Place the affected extremity in traction. C) Immobilize the affected extremity. D) Notify the primary healthcare provider on call.

C

Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? A) Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. B) Arrange for a supply of heparin for the client to take to the rehab center. C) Explain to the client that anticoagulant therapy will no longer be needed. D) Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.

A

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply. A) Sharp chest pain B) Acute onset of dyspnea C) Pain in the residual limb D) Absence of the popliteal pulse E) Blanching of the affected extremity

A, B

A nurse is caring for a client with compartment syndrome. Which nursing actions are appropriate? Select all that apply. A) Assisting with splitting the cast B) Assessing urine output C) Evaluating the pain on a scale D) Applying splints to the injured part E) Placing cold compresses to the affected area

A, B, C

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? A) Limit the client's fluid intake. B) Teach the client how to exercise the legs. C) Encourage use of the incentive spirometer. D) Maintain the knee gatch position at an angle.

B

After a deep vein thrombosis developed in a postpartum client, an intravenous (IV) infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do next? A) Increase the IV rate of heparin. B) Interrupt the infusion and notify the primary healthcare provider of the aPTT result. C) Document the result on the medical record and recheck the aPTT in 4 hours. D) Call the primary healthcare provider to obtain a prescription for a low-molecular-weight heparin.

B

The healthcare provider has prescribed enoxaparin 1 mg/kg for a client who had a total knee replacement. The client weighs 187 pounds (85 kg). This medication is available in a concentration of 30 mg/0.3 mL. What dose will the nurse administer in milliliters? A) 0.8 mL B) 0.85 mL C) 0.9 mL D) 0.95 mL

B

The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome? A) Warm skin at the site of injury B) Escalating pain in the fingers C) Rapid capillary refill in affected hand D) Bounding radial pulse in the injured arm

B

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? A) Pregnancy B) Inactivity C) Aerobic exercise D) Tight clothing

B

To prevent excessive bruising when administering subcutaneous heparin, what technique will the nurse employ? A) Administer the injection via the Z-track technique B) Avoid massaging the injection site after the injection C) Use 2 mL of sterile normal saline to dilute the heparin D) Inject the drug into the vastus lateralis muscle in the thigh

B

Which client is at greatest risk for the development of a venous thrombosis? A) A 76-year-old female with a 100-pack-per-year smoking history and hypertension B) A 68-year-old male on bed rest following a left hip fracture C) A 59-year-old male who is an intravenous drug user with hyperlipidemia D) A 42-year-old female with Factor V Leiden mutation on warfarin

B

Which clinical manifestation can a client experience during a fat embolism syndrome (FES)? A) Nausea B) Dyspnea C) Orthopnea D) Paresthesia

B

Which factor does the nurse consider most likely contributes to the increased incidence of hip fractures in older adults? A) Carelessness B) Fragility of bone C) Sedentary existence D) Rheumatoid diseases

B

The registered nurse is evaluating the actions of a nursing student who is providing care to a client with compartment syndrome. Which action of the nursing student does the registered nurse think needs correction? Select all that apply. A) Bivalving the cast B) Applying cold compresses C) Loosening the bandage applied D) Evaluating the client's level of pain E) Elevating the extremity above heart level

B, E

A client with a suspected pulmonary embolism is scheduled for a spiral computed tomography scan. Which intervention should the nurse perform when preparing the client for the test? A) Check the client's blood glucose levels. B) Obtain informed consent from the client. C) Assess if the client is allergic to shellfish. D) Instruct the client to remove his or her dentures.

C

The primary healthcare provider prescribes one unit of packed red blood cells to be administered to the client who suffered a hip fracture. Several minutes after the start of the infusion, the client reports itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next? A) Call the primary healthcare provider to obtain a prescription for an antihistamine. B) Flush packed red blood cells with 5% dextrose and 0.45% normal saline. C) Slow down the rate of the infusion. D) Stop the transfusion immediately.

D

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? A) Fever and chest pain B) Positive Homans sign C) Loss of sensation in the operative leg D) Tachycardia and petechiae over the chest

D

A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin? A) Atenolol B) Ferrous sulfate C) Chlorpromazine D) Acetylsalicylic acid

D

A client with a history of pulmonary emboli is taking warfarin daily. The nurse teaches the client about foods that are appropriate to consume when taking this medication. The nurse evaluates that the client needs further teaching when the client makes which statement? A) "Eggs provide a good source of iron, which is needed to prevent anemia." B) "Yellow vegetables are high in vitamin A and should be included in the diet." C) "Fish and shrimp are iodine-rich food sources that can prevent hypothyroidism." D) "Dark green leafy vegetables are high in vitamin K so I should eat them more often."

D

Enoxaparin 40 mg subcutaneously daily is prescribed for a client who had abdominal surgery. The nurse explains that the medication is given for what purpose? A) Control postoperative fever B) Provide a constant source of mild analgesia C) Limit the postsurgical inflammatory response D) Provide prophylaxis against postoperative thrombus formation

D

The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? A) Oxygen therapy B) Cardiac monitoring C) Nutrition supplements D) Venous thromboembolism (VTE) prevention

D