DVT (DEEP VEIN THROMBOSIS) EXAM Q’S AND A’S

DVT (DEEP VEIN THROMBOSIS) EXAM Q’S AND A’S The nurse is completing an assessment on a newly admitted client. What finding would alert the nurse that the client may be experiencing a deep venous thrombosis (DVT)? A) Shortness of breath after activity B) Two-plus palpable pedal pulses C) Swelling in one leg with edema D) Sharp pain in both legs - answer- Answer: C Explanation: A) Manifestations of DVT include swelling in one leg with pitting edema because the clot is obstructing the venous return from the leg. Shortness of breath that subsides after activity and two-plus palpable pulses are not manifestations of DVT. Pain in the affected extremity is usually dull and aching, not sharp. The nurse is planning care for a group of clients. Which client should the nurse identify as having the greatest risk for developing deep venous thrombosis (DVT)? 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 - answer- Answer: D Explanation: A) Between 40% and 85% of clients recovering from total knee replacement surgery develop a DVT 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 DVT because prolonged immobility will not occur. The nurse is caring for a breastfeeding client recovering from a cesarean section. The physician diagnoses her with superficial venous thrombosis. Which intervention should the nurse anticipate carrying out first? A) Encourage to ambulate freely B) Aspirin 650 mg every 4 hours C) Apply warm, moist compresses D) Provide methylergonovine (Methergine) IM - answer- Answer: C Explanation: A) The treatment for superficial venous thrombosis involves resting the extremity, administering anti-inflammatory agents, and applying warm, moist compresses over the affected vein. Ambulation would increase the inflammation. Heparin or warfarin is preferred over aspirin for treatment of venous thrombosis, and both are safe for lactating mothers. Methylergonovine 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 (DVT). Which problem would be a priority for this client? A) Infection B) Fluid volume C) Peripheral perfusion D) Sleep pattern - answer- Answer: C Explanation: A) Ineffective peripheral tissue perfusion is the priority, because it is related to obstructed venous return, which is the underlying cause of the DVT. Risk for infection would be a priority if complications of infection were present; however, this is not the case. Excess fluid volume and disturbed sleep pattern are incorrect because they are not related to the underlying cause. The nurse is providing discharge teaching to a client recovering from deep venous thrombosis (DVT). Which instructions are appropriate for the nurse to include in the teaching session? 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 - answer- Answer: A, C, D Explanation: A) The client should be instructed to avoid crossing the legs because it increases pressure on the veins of the lower extremities. The client should also be instructed 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 does not need to be instructed to avoid long car trips but rather to take frequent breaks during long car trips. 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 DVT. A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is 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. - answer- Answer: C Explanation: A) An absence of bleeding is a priority outcome for any clie