Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for the following four clients on the nursing unit.
Which client is at the highest risk for the development of deep vein thrombosis?
A. 55-year-old man with a past medical history of a myocardial infarction.
While a past medical history of myocardial infarction does increase the risk of deep vein thrombosis (DVT), it is not the highest risk factor among the options provided. Other factors such as immobility, surgery, and certain medical conditions can pose a higher risk.
B. 45-year-old woman post laparoscopic knee replacement.
Postoperative patients, such as those who have had a laparoscopic knee replacement, are at an increased risk for DVT due to periods of immobility and changes in blood flow and clotting. However, the risk is not as high as in patients who have undergone major open abdominal surgery.
C. 65-year-old woman post major open abdominal surgery.
Patients who have undergone major open abdominal surgery are at the highest risk for the development of DVT among the options provided. The surgery itself, along with the postoperative period of immobility, significantly increases the risk of DVT34567.
D. 50-year-old man with a peptic ulcer.
While peptic ulcers can be associated with certain risk factors for DVT, such as age and immobility due to pain, they do not pose as high a risk as major open abdominal surgery.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Nurs 200 Proctored Exam Roxoborouh Memorial College. Take the full exam now
Full Explanation
Choice A rationale
While a past medical history of myocardial infarction does increase the risk of deep vein thrombosis (DVT), it is not the highest risk factor among the options provided. Other factors such as immobility, surgery, and certain medical conditions can pose a higher risk.
Choice B rationale
Postoperative patients, such as those who have had a laparoscopic knee replacement, are at an increased risk for DVT due to periods of immobility and changes in blood flow and clotting.
However, the risk is not as high as in patients who have undergone major open abdominal surgery.
Choice C rationale
Patients who have undergone major open abdominal surgery are at the highest risk for the development of DVT among the options provided. The surgery itself, along with the postoperative period of immobility, significantly increases the risk of DVT34567.
Choice D rationale
While peptic ulcers can be associated with certain risk factors for DVT, such as age and immobility due to pain, they do not pose as high a risk as major open abdominal surgery.
Similar Questions
A client has been taking glipizide for 6 months and reports to the nurse that their urine has become darker since starting the medication.
What should be the nurse’s initial action?
A. Review the results of liver function studies.
Dark urine can be a sign of liver dysfunction, which can be a side effect of glipizide. Therefore, reviewing the results of liver function studies would be an appropriate initial action to determine if the medication is affecting the client’s liver function.
B. Instruct the client to increase their water intake.
While increasing water intake can sometimes help with certain side effects of medications, it would not address the potential issue of liver dysfunction indicated by the dark urine.
C. Check the client’s weight.
Checking the client’s weight would not provide information related to the cause of the dark urine.
D. Test a sample of urine for the presence of occult blood.
Testing a sample of urine for the presence of occult blood could be useful if there was a suspicion of bleeding, but it would not address the potential issue of liver dysfunction indicated by the dark urine.
Full Explanation
Choice A rationale
Dark urine can be a sign of liver dysfunction, which can be a side effect of glipizide. Therefore, reviewing the results of liver function studies would be an appropriate initial action to determine if the medication is affecting the client’s liver function.
Choice B rationale
While increasing water intake can sometimes help with certain side effects of medications, it would not address the potential issue of liver dysfunction indicated by the dark urine.
Choice C rationale
Checking the client’s weight would not provide information related to the cause of the dark urine.
Choice D rationale
Testing a sample of urine for the presence of occult blood could be useful if there was a suspicion of bleeding, but it would not address the potential issue of liver dysfunction indicated by the dark urine.
The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities.
What should be the nurse’s initial action?
A. Hold the warfarin until the next day’s dose and notify the laboratory.
While holding the warfarin and notifying the laboratory could be appropriate actions in some situations, they would not address the immediate concern of the large, new ecchymotic areas on the client’s extremities.
B. Administer the daily dose of warfarin and notify the healthcare provider so tomorrow’s dose can be adjusted.
Administering the daily dose of warfarin and notifying the healthcare provider for a dose adjustment the next day could potentially exacerbate the bleeding risk, given the presence of the large, new ecchymotic areas.
C. Administer the daily dose of warfarin as these are the expected side effects of the medication.
Large, new ecchymotic areas are not expected side effects of warfarin. They could indicate a serious problem such as excessive anticoagulation.
D. Hold the warfarin until the healthcare provider is notified of the assessment findings.
The presence of large, new ecchymotic areas could indicate excessive anticoagulation, which is a serious complication of warfarin therapy. Therefore, holding the warfarin and notifying the healthcare provider of the assessment findings would be the most appropriate initial action.
Full Explanation
Choice A rationale
While holding the warfarin and notifying the laboratory could be appropriate actions in some situations, they would not address the immediate concern of the large, new ecchymotic areas on the client’s extremities.
Choice B rationale
Administering the daily dose of warfarin and notifying the healthcare provider for a dose adjustment the next day could potentially exacerbate the bleeding risk, given the presence of the large, new ecchymotic areas.
Choice C rationale
Large, new ecchymotic areas are not expected side effects of warfarin. They could indicate a serious problem such as excessive anticoagulation.
Choice D rationale
The presence of large, new ecchymotic areas could indicate excessive anticoagulation, which is a serious complication of warfarin therapy. Therefore, holding the warfarin and notifying the healthcare provider of the assessment findings would be the most appropriate initial action.
A newly admitted client has been prescribed trimethoprim-sulfamethoxazole.
The nurse understands that this medication is contraindicated based on which lab result?
A. Serum fasting glucose of 101 mg/dL.
A serum fasting glucose of 101 mg/dL is slightly above the normal range (70-100 mg/dL), indicating a possible prediabetes condition. However, it is not a contraindication for trimethoprim-sulfamethoxazole.
B. Platelets of 160,000 uL.
A platelet count of 160,000 uL is within the normal range (150,000-450,000 uL). Therefore, it is not a contraindication for trimethoprim-sulfamethoxazole.
C. Hemoglobin of 13.6 g/dL.
]A hemoglobin level of 13.6 g/dL is within the normal range for both men (13.5-17.5 g/dL) and women (12.0-15.5 g/dL). Thus, it is not a contraindication for trimethoprim-sulfamethoxazole.
D. Serum creatinine of 2.5 mg/dL.
A serum creatinine level of 2.5 mg/dL is above the normal range (0.6-1.2 mg/dL for men, 0.5- 1.1 mg/dL for women), indicating impaired kidney function. Trimethoprim-sulfamethoxazole is contraindicated in patients with severe renal insufficiency.
Full Explanation
Choice A rationale
A serum fasting glucose of 101 mg/dL is slightly above the normal range (70-100 mg/dL), indicating a possible prediabetes condition. However, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice B rationale
A platelet count of 160,000 uL is within the normal range (150,000-450,000 uL). Therefore, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice C rationale
A hemoglobin level of 13.6 g/dL is within the normal range for both men (13.5-17.5 g/dL) and women (12.0-15.5 g/dL). Thus, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice D rationale
A serum creatinine level of 2.5 mg/dL is above the normal range (0.6-1.2 mg/dL for men, 0.5- 1.1 mg/dL for women), indicating impaired kidney function. Trimethoprim-sulfamethoxazole is contraindicated in patients with severe renal insufficiency.