which assessment finding is most indicative of deep vein thrombosis dvt in a clients right leg
Logo

Nursing Elites

HESI RN

HESI RN CAT Exit Exam 1

1. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?

Correct answer: C

Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.

2. The nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client. Which action is most important for the nurse to take?

Correct answer: A

Rationale: Verifying the client's blood type is crucial before administering PRBCs to ensure compatibility and prevent transfusion reactions. Checking the client's blood type is essential in blood transfusions. Ensuring the PRBCs are warm is not a priority as the temperature should be within a specific range regardless of the client's preference. Checking the client's vital signs is important but not as crucial as verifying the blood type before a blood transfusion. Obtaining the client's consent is important for any procedure but does not directly impact the safety and success of administering PRBCs.

3. The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?

Correct answer: C

Rationale: Pain in the lower back is a significant finding in an older client as it can indicate underlying issues such as kidney problems, spinal issues, or even aortic aneurysm. These conditions can be serious and require prompt medical attention. Decreased urine output (choice A) could indicate dehydration or kidney issues but is not as urgent as lower back pain. Loss of appetite (choice B) may be concerning but is not as critical as the potential life-threatening conditions associated with lower back pain. A persistent cough (choice D) is important to assess but is generally not as urgent as the potential serious implications of lower back pain in an older client.

4. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?

Correct answer: A

Rationale: Choice A is the best response because it educates the client about the role of heparin in preventing future clot formation rather than dissolving the existing clot. This helps the client understand the medication's function and the importance of closely monitoring for signs of bleeding, a common side effect of heparin therapy. Choice B acknowledges the client's concern but does not provide accurate information about heparin's mechanism of action. Choice C is premature as it suggests transitioning to home therapy without addressing the client's concerns or explaining heparin's purpose. Choice D does not address the client's statement and instead questions their desire to leave the hospital.

5. When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?

Correct answer: A

Rationale: The correct calculation for infusion based on the given data is 5 ml/hr. To calculate the infusion rate per hour, you need to determine the number of contractions per hour. If contractions are occurring every 2-3 minutes, this would mean approximately 20-30 contractions per hour. Therefore, if the pump is infusing 5 ml per contraction, the total infusion rate per hour would be 5 ml x 20 contractions = 100 ml/hr. This makes choice A the correct answer. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.

Similar Questions

A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?
When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective?
A client who had a cerebral vascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?
A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select one that doesn't apply.)

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses