Introduction
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is caring for a postpartum client who had a cesarean birth.
Which of the following actions should the nurse take to prevent DVT in this client?
Explanation
The correct answer is choice B. Encourage early and frequent ambulation.This action helps to prevent DVT by keeping the blood flowing in the lower legs and reducing venous stasis.Early and frequent ambulation is also recommended by various clinical guidelines for postpartum VTE prevention.
Choice A is wrong because applying a heating pad to the lower legs does not prevent DVT and may increase the risk of bleeding or infection.
Choice C is wrong because placing a pillow under the knees when in bed does not prevent DVT and may worsen venous stasis by compressing the iliac veins.
Choice D is wrong because massaging the affected limb gently does not prevent DVT and may dislodge a clot or cause damage to the vein wall.
A nurse is assessing a postpartum client who reports leg pain and tenderness.
The nurse observes unilateral swelling, warmth, and redness of the lower extremity.
Which of the following conditions should the nurse suspect?
Explanation
The correct answer is choice B. Deep vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the leg.It can cause pain, swelling, redness and warmth in the affected area.DVT is more serious than superficial thrombophlebitis, which is inflammation of a vein near the skin due to a blood clot.DVT can lead to complications such as pulmonary embolism, which is a life-threatening condition where the blood clot travels to the lungs and blocks an artery.
Choice A is wrong because superficial thrombophlebitis is not as severe as DVT and does not usually cause swelling of the whole leg.
Choice C is wrong because pulmonary embolism is not a condition of the leg, but a complication of DVT that affects the lungs.
Choice D is wrong because idiopathic thrombocytopenic purpura (ITP) is a disorder that causes low platelet count and bleeding problems, not blood clots.
Normal ranges for platelet count are 150,000 to 450,000 platelets per microliter of blood.Normal ranges for D-dimer test are less than 0.5 micrograms per milliliter of blood.
A nurse is teaching a postpartum client who is at high risk for venous insufficiency about measures to prevent thrombophlebitis.
Which of the following instructions should the nurse include? (Select all that apply.)
Explanation
The correct answer is choice A, B, D and E. These are measures to prevent thrombophlebitis, which is a condition where a blood clot forms in a vein and causes inflammation and pain.
Thrombophlebitis can lead to serious complications such as pulmonary embolism, which is a life-threatening condition where a blood clot travels to the lungs and blocks the blood flow.
Choice A is correct because wearing fitted elastic thromboembolic hose can help compress the veins and improve the blood flow in the legs, reducing the risk of clot formation.
Choice B is correct because drinking 2 to 3 L of fluid per day can help prevent dehydration, which can make the blood thicker and more prone to clotting.
Choice D is correct because elevating your legs above your heart level can help reduce the pressure and swelling in the veins, improving the blood circulation and preventing stasis.
Choice E is correct because smoking can damage the lining of the blood vessels, increase the blood pressure and heart rate, and make the blood more sticky and likely to clot.
Choice C is wrong because crossing your legs when sitting can impair the blood flow in the legs and increase the risk of thrombophlebitis.
It is recommended to avoid prolonged sitting and to move your legs frequently.
Normal ranges for fluid intake are about 2 to 3 L per day for adults, depending on age, weight, activity level and health conditions.
Normal ranges for leg elevation are about 15 to 30 degrees above the heart level.
A nurse is reviewing the laboratory results of a postpartum client who has idiopathic thrombocytopenic purpura (ITP).
Which of the following findings should the nurse expect?
Explanation
The correct answer is choice A. Decreased platelet count.ITP is a disorder that causes low levels of platelets due to immune system malfunction or increased breakdown of platelets.
Platelets are blood cells that control bleeding and prevent bruising.Normal platelet count ranges from 150,000 to 450,000 per microliter of blood.
Choice B is wrong because increased prothrombin time means prolonged clotting time, which is not a feature of ITP.Prothrombin time measures how long it takes for the blood to clot and is affected by factors such as liver disease, vitamin K deficiency, or blood-thinning medications.
Choice C is wrong because decreased fibrinogen level means reduced ability to form blood clots, which is not a feature of ITP.Fibrinogen is a protein that helps the blood to clot and is affected by factors such as liver disease, inflammation, infection, or trauma.
Choice D is wrong because increased partial thromboplastin time means prolonged clotting time, which is not a feature of ITP.Partial thromboplastin time measures how long it takes for the blood to clot and is affected by factors such as hemophilia, lupus, or blood-thinning medications.
A nurse is monitoring a postpartum client who has disseminated intravascular coagulation (DIC).
Which of the following manifestations should the nurse report to the provider immediately?
Explanation
The correct answer is choice C. Tachycardia and hypotension.
These are signs of shock due to severe blood loss and should be reported to the provider immediately.DIC can cause both excessive clotting and bleeding, which can lead to organ damage and death.
Choice A is wrong because petechiae on the chest and abdomen are common manifestations of DIC due to low platelet count and increased fibrin degradation products.
They are not life-threatening by themselves and do not require immediate intervention.
Choice B is wrong because hematuria in the urinary catheter bag is another manifestation of DIC due to bleeding in the urinary tract.
It is not an emergency unless it is accompanied by other signs of shock or renal failure.
Choice D is wrong because oozing of blood from IV site is also a manifestation of DIC due to impaired coagulation.
It can be managed by applying pressure and changing the dressing.
It is not a priority over signs of shock.
Normal ranges for platelet count are 150,000 to 450,000 per microliter of blood, for fibrinogen level are 200 to 400 mg/dL, for prothrombin time are 11 to 13.5 seconds, for partial thromboplastin time are 25 to 35 seconds, and for D-dimer level are less than 0.5 mcg/mL.
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