Question

A nurse is reinforcing teaching with a newly licensed nurse about causative risk factors for deep vein thrombosis (DVT). Which of the following should be included in the teaching? (Select All that Apply.)

Answer 1

Correct Answers:

Immobility
Fracture
Estrogen therapy

Rationale :

Immobility

💎Lack of movement leads to venous stasis, a key component of Virchow’s Triad (stasis, endothelial injury, hypercoagulability) that increases risk for DVT.

💎Prolonged bedrest, long travel, or postoperative immobility slows blood flow, allowing clots to form.

💎Early ambulation, compression devices, and leg exercises are crucial preventive strategies.

Fracture

💎Bone fractures, especially of the pelvis, hip, or leg, cause endothelial damage and release of tissue factors, both of which promote clot formation.

💎Orthopedic injuries are among the highest risk factors for DVT development.

💎Post-fracture patients often require anticoagulant prophylaxis and mechanical compression therapy.

Estrogen therapy

💎Estrogen-containing medications (e.g., oral contraceptives, hormone replacement therapy) increase coagulability of blood, raising the risk for thromboembolic events.

💎Estrogen promotes clotting factor synthesis in the liver and reduces natural anticoagulants.

💎Women taking estrogen therapy are counseled about lifestyle risk reduction, especially smoking cessation, to lower clot risk.

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Answer 2

Correct Answers:

Abscess

Rationale :

🔴 An abscess is a hallmark of a localized infection, characterized by swelling, redness, pain, and accumulation of pus in one specific area.

🔴 Localized infections affect a defined tissue or organ, unlike systemic infections that manifest with fever, tachycardia, or confusion.

🔴 The nurse should monitor the abscess for changes in size, drainage, and surrounding tissue inflammation.

🔴 Prompt recognition helps prevent progression into a systemic infection (sepsis).

🔴 This finding requires appropriate wound care and may require incision and drainage.

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Answer 3

Correct Answers:

Intracranial bleed

Rationale :

☑️An intracranial hemorrhage leads to increased intracranial pressure (ICP), and headache is one of the earliest and most common symptoms.

☑️This occurs due to compression of brain tissue and impaired cerebrospinal fluid circulation.

☑️Other manifestations include nausea, vomiting, altered mental status, and neurological deficits.

☑️Early identification of headache in a client at risk for bleeding is critical to prevent herniation and permanent brain damage.

☑️The nurse should closely monitor neuro status, pupils, and vital signs.

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Answer 4

Correct Answers

Narcotic analgesics [ Anticipated ]
Serum uric acid levels [ Nonessential ]
INSAIDS [ Anticipated ]
Mobility Aid Education [ Anticipated ]
Arthroplasty [ Anticipated ]
C-reactive protein lab [ Nonessential ]
Increased bedrest [ Contraindicated ]
Physical Therapy [ Anticipated ]
Fall risk precautions [ Anticipated ]
Arthrocentesis [ Nonessential ]

Rationale :

Anticipated

Narcotic analgesics

🔷 The client reports severe pain (9/10) and inability to perform ADLs, so short-term opioid therapy is appropriate to rapidly control acute pain while other measures are initiated.

🔷 In older adults with refractory OA flares, a brief course can restore mobility and allow participation in PT and self-care.

🔷 Use the lowest effective dose with bowel regimen and sedation monitoring to minimize constipation, delirium, and falls.

🔷 Opioids are a bridge, not long-term OA therapy, and should be reassessed frequently for continued need.

🔷 This plan aligns with pain-management standards: function-focused, time-limited, and combined with non-opioids.

NSAIDs

🟩 NSAIDs are first-line pharmacologic therapy for osteoarthritis and reduce pain and activity-related inflammation around degenerative joints.

🟩 Imaging shows joint-space loss/osteophytes consistent with OA, making NSAIDs an evidence-based choice for symptom control.

🟩 Given daily aspirin use, assess GI risk and consider PPI co-therapy or topical NSAIDs to reduce bleeding risk.

🟩 Monitor renal function and BP, especially in older adults.

🟩 Properly dosed NSAIDs often improve function enough to engage safely in PT.

Mobility aid education

🟦 Near-falls and difficulty rising indicate high fall risk and knee weakness/stiffness; teaching cane/walker use immediately improves stability.

🟦 Correct device fit and technique (e.g., cane on contralateral side) reduces joint load and pain.

🟦 Education supports independence, safer transfers, and confidence during ambulation.

🟦 Reinforce home-safety tips (clutter removal, lighting) to prevent injury after discharge.

🟦 Documentation of competency and ongoing reinforcement are part of safe mobility planning.

Arthroplasty

🟨 Severe functional limitation, persistent high pain despite OTCs, and radiographic OA make orthopedic evaluation for joint replacement reasonable.

🟨 Total knee/hip arthroplasty provides substantial pain relief and quality-of-life gains when conservative therapy fails.

🟨 Timing depends on shared decision-making, comorbidity optimization, and social support planning.

🟨 Prehab and postoperative rehab are crucial to outcomes; flag early so preparation can begin.

🟨 As a future intervention, it aligns with the client’s goal of regaining functional independence.

Physical therapy

🟪 PT targets strength (e.g., quadriceps), ROM, and gait mechanics, which reduces pain and improves balance.

🟪 Therapists teach joint-protective strategies, pacing, and home exercise programs tailored to OA.

🟪 PT decreases fall risk and supports safer ADLs, matching this client’s needs.

🟪 Early PT counters deconditioning from recent immobility and pain.

🟪 It is a cornerstone of non-operative OA management with strong functional benefits.

Fall risk precautions

🟥 Recent near-falls, lower-extremity stiffness, and severe pain warrant immediate fall-prevention protocols.

🟥 Use nonskid footwear, bed in low position, call-light within reach, and hourly rounding.

🟥 Consider assistive devices and supervised ambulation until strength and pain improve.

🟥 Preventing fractures in older adults averts major morbidity and loss of independence.

🟥 Incorporate multidisciplinary input (RN, PT, OT) for comprehensive safety.

Nonessential

Serum uric acid levels

🟠 Presentation and imaging (bilateral joint-space loss/osteophytes) point to OA, not gout; no acute monoarticular redness/warmth or tophi.

🟠 Uric acid testing won’t change immediate OA management and may divert resources.

🟠 Reserve for episodes suggestive of crystal arthritis.

🟠 Prioritize pain control, function, and safety first.

🟠 Order later only if clinical features evolve toward gout.

C-reactive protein (CRP) lab

🔵 OA is typically non-inflammatory systemically; CRP is often normal and adds little to acute decision-making here.

🔵 Elevated CRP would steer evaluation toward RA/infection, which the current data don’t suggest.

🔵 Focus labs on safety for NSAIDs/opioids (renal function, CBC if indicated) rather than CRP.

🔵 Use CRP selectively if new systemic signs appear.

🔵 This keeps care targeted and efficient.

Arthrocentesis

🟤 Indicated for suspected septic arthritis or crystal disease; this client lacks fever, acute monoarthritis, or intense joint erythema.

🟤 Multi-joint chronic pain with OA changes doesn’t typically benefit from diagnostic taps.

🟤 Procedures add risk (bleeding, infection) without clear indication.

🟤 Reserve if clinical picture shifts (hot, swollen single joint; systemic illness).

🟤 Current priority is analgesia, mobility, and fall prevention.

Contraindicated

Increased bedrest

⚫ Bedrest worsens stiffness, deconditioning, thromboembolism risk, and constipation in older adults with OA.

⚫ OA improves with graded movement, not immobilization; immobility also increases fall risk once walking resumes.

⚫ Encourage early, assisted mobilization with PT and safe analgesia.

⚫ Use rest periods strategically, but avoid prescribing “increased bedrest.”

⚫ Mobility is central to maintaining function and independence.

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Answer 5

Correct Answers:

"The culture is needed to determine whether the infection is bacterial. If it is bacterial, knowing the kind of bacteria helps the physician determine which antibiotic you need.”

Rationale :

💎 This response is therapeutic and educational, explaining the purpose of the culture in clear, patient-centered terms.

💎 A wound may appear infected, but not all infections are bacterial; some can be fungal or viral, requiring different treatment.

💎 Even if bacterial, different organisms require different antibiotics—culture and sensitivity testing ensures the most effective, targeted therapy is prescribed.

💎 This reduces the risk of antibiotic resistance, ineffective treatment, and complications from inappropriate antibiotic use.

💎 It also supports the principle of antibiotic stewardship, ensuring safe and evidence-based prescribing.

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Answer 6

Correct Answers:

Mask

Rationale :

⏺️Influenza spreads primarily by droplet transmission (coughing, sneezing, talking), which can travel up to 6 feet.

⏺️The client should wear a surgical mask to contain respiratory secretions when being transported or when around others.

⏺️This reduces the risk of spreading influenza to healthcare staff, visitors, and other patients.

⏺️Gloves, gowns, and goggles may be used by healthcare workers if exposure to secretions is anticipated, but the priority for the client is wearing a mask.

⏺️Mask use aligns with CDC droplet precautions for influenza management.

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Answer 7

Correct Answers:

Avoid crossing your legs when sitting.
Move frequently while on an airplane.
Discontinue estrogen therapy if your medical provider recommends.
Stop smoking and avoid secondhand smoke.

Rationale :

Avoid crossing your legs when sitting

💎 Crossing the legs causes venous stasis by compressing veins in the legs, increasing risk for clot formation.

💎 Teaching clients to sit with legs uncrossed and feet flat promotes healthy circulation.

💎 Especially important for individuals with a history of vascular disease or immobility.

Move frequently while on an airplane

💎 Long periods of immobility during travel contribute to venous stasis and DVT.

💎 Walking, stretching calves, or doing ankle pumps improves blood return.

💎 Clients should aim for movement every 1–2 hours during flights or car trips.

Discontinue estrogen therapy if your medical provider recommends

💎 Estrogen therapy increases clotting risk by raising clotting factor production and reducing natural anticoagulants.

💎 Women at risk for DVT may be advised to stop estrogen-containing medications (e.g., oral contraceptives, HRT).

💎 Always done under provider supervision to balance risks and benefits.

Stop smoking and avoid secondhand smoke

💎 Smoking causes vascular endothelial damage and increases platelet aggregation, both of which promote clot formation.

💎 Stopping smoking significantly lowers DVT and cardiovascular risk.

💎 Avoiding secondhand smoke also reduces systemic vascular damage.

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Answer 8

Correct Answers:

Ability to target and destroy CD4 lymphocytes

Rationale :

♦️HIV primarily attacks CD4 T lymphocytes (helper T cells), which are essential for coordinating the body’s immune response.

♦️As the virus replicates and destroys these cells, the client’s CD4 count decreases, weakening immunity.

♦️A reduced CD4 count (<200 cells/mm³) defines AIDS and significantly increases vulnerability to opportunistic infections such as Pneumocystis jiroveci pneumonia, Kaposi sarcoma, and candidiasis.

♦️The destruction of CD4 cells is what makes HIV uniquely dangerous, as the body can no longer effectively fight common pathogens.

♦️While reverse transcriptase and RNA features define how HIV replicates, the loss of CD4 immunity is what directly causes opportunistic infections.

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Answer 9

Correct Answers:

Steak
Low fat milk
Grilled salmon
Scrambled eggs

Rationale :

Steak

🥩 Rich in vitamin B12, which is found naturally only in animal products.

🥩 Including red meat helps replenish stores needed for red blood cell production and neurological function.

🥩 Especially important in clients with deficiency-related anemia.

Low fat milk

🥛 Dairy products like milk, yogurt, and cheese provide a good source of vitamin B12.

🥛 Encouraging low-fat options supports both cardiovascular health and nutrient replacement.

🥛 Important for clients who may not tolerate red meat.

Grilled salmon

🐟 Salmon and other fish are excellent sources of vitamin B12 and omega-3 fatty acids.

🐟 Including fish supports neurologic health and reduces inflammation, which benefits overall well-being.

🐟 A frequent dietary recommendation in B12 deficiency diets.

Scrambled eggs

🥚 Eggs, especially the yolk, contain vitamin B12 and are a versatile source of protein.

🥚 They are a good option for clients who may not eat large amounts of red meat or fish.

🥚 Easy to digest and incorporate into daily meals.

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Answer 10

Correct Answers:

D-dimer blood test
CT scan
Lung ventilation and perfusion scan (VQ scan)

Rationale :

D-dimer blood test

🫁 Elevated D-dimer levels indicate active clot formation and breakdown, which can suggest PE.

🫁 While not specific, a negative D-dimer can help rule out PE in low-risk clients.

🫁 Often ordered as a first-line, rapid screening tool before imaging.

CT scan

🫁 The gold standard diagnostic test for PE.

🫁 Directly visualizes the pulmonary arteries and identifies the location and size of the clot.

🫁 Provides quick and accurate results, guiding immediate treatment decisions.

Lung ventilation and perfusion (V/Q) scan

🫁 Useful when CT is contraindicated (e.g., renal impairment, iodine contrast allergy).

🫁 Detects mismatched areas of ventilation (air flow) and perfusion (blood flow), which is characteristic of PE.

🫁 A valuable alternative, especially in pregnant clients or those with poor kidney function.

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QLexNursing

1 :
A nurse is reinforcing teaching with a newly licensed nurse about causative risk factors for deep vein thrombosis (DVT). Which of the following should be included in the teaching? (Select All that Apply.)

2 :
A nurse is providing care to a client who has an infection. Which of the following findings is a localized manifestation that the nurse should monitor for?

3 :
A charge nurse is reinforcing teaching a group of newly licensed nurses about hemorrhage. Which of the following types of hemorrhage should the nurse include as having a headache as a manifestation?

4 :
A nurse is caring for an elderly client on the medical surgical floor.

Correct Answers

5 :
A nurse is providing care to a client who has a skin infection. The client questions the necessity of testing "Why do you need to take a culture? It's clearly infected. Just give me some amoxicillin and let me go home." Which of the following responses by the nurse is most appropriate?

6 :
A nurse is caring for a client who has influenza. Which of the following personal protective equipment (PPE) should the nurse instruct the client to wear?

7 :
A nurse is reinforcing teaching with a client about the prevention of deep vein thrombosis DVT). Which of the following recommendations should the nurse include in the teaching? (Select All that Apply.)

8 :
A nurse is reinforcing education provided to a client who has HIV about the infection process. Which of the following features of the virus should the nurse explain can result in opportunistic infection?

9 :
A nurse is reinforcing dietary teaching to a client who has a new onset of vitamin Bl 2 deficiency. Which of the following foods should the nurse encourage the client to include in their diet? (Select All that Apply.)

10 :
A nurse is assisting with the care of a client who has developed pulmonary embolism (PE). Which of the following diagnostic tests should the nurse anticipate the provider to prescribe to confirm the clients condition? (Select All that Apply.)

Potential Provider Order	Anticipated	Nonessential	Contraindicated
Narcotic analgesics
Serum uric acid levels
INSAIDS
Mobility Aid Education
Arthroplasty
C-reactive protein lab
Increased bedrest
Physical Therapy
Fall risk precautions
Arthrocentesis

QLexNursing

1 : A nurse is reinforcing teaching with a newly licensed nurse about causative risk factors for deep vein thrombosis (DVT). Which of the following should be included in the teaching? (Select All that Apply.)

2 : A nurse is providing care to a client who has an infection. Which of the following findings is a localized manifestation that the nurse should monitor for?

3 : A charge nurse is reinforcing teaching a group of newly licensed nurses about hemorrhage. Which of the following types of hemorrhage should the nurse include as having a headache as a manifestation?

4 : A nurse is caring for an elderly client on the medical surgical floor.

Correct Answers

5 : A nurse is providing care to a client who has a skin infection. The client questions the necessity of testing "Why do you need to take a culture? It's clearly infected. Just give me some amoxicillin and let me go home." Which of the following responses by the nurse is most appropriate?

6 : A nurse is caring for a client who has influenza. Which of the following personal protective equipment (PPE) should the nurse instruct the client to wear?

7 : A nurse is reinforcing teaching with a client about the prevention of deep vein thrombosis DVT). Which of the following recommendations should the nurse include in the teaching? (Select All that Apply.)

8 : A nurse is reinforcing education provided to a client who has HIV about the infection process. Which of the following features of the virus should the nurse explain can result in opportunistic infection?

9 : A nurse is reinforcing dietary teaching to a client who has a new onset of vitamin Bl 2 deficiency. Which of the following foods should the nurse encourage the client to include in their diet? (Select All that Apply.)

10 : A nurse is assisting with the care of a client who has developed pulmonary embolism (PE). Which of the following diagnostic tests should the nurse anticipate the provider to prescribe to confirm the clients condition? (Select All that Apply.)

1 :
A nurse is reinforcing teaching with a newly licensed nurse about causative risk factors for deep vein thrombosis (DVT). Which of the following should be included in the teaching? (Select All that Apply.)

2 :
A nurse is providing care to a client who has an infection. Which of the following findings is a localized manifestation that the nurse should monitor for?

3 :
A charge nurse is reinforcing teaching a group of newly licensed nurses about hemorrhage. Which of the following types of hemorrhage should the nurse include as having a headache as a manifestation?

4 :
A nurse is caring for an elderly client on the medical surgical floor.

5 :
A nurse is providing care to a client who has a skin infection. The client questions the necessity of testing "Why do you need to take a culture? It's clearly infected. Just give me some amoxicillin and let me go home." Which of the following responses by the nurse is most appropriate?

6 :
A nurse is caring for a client who has influenza. Which of the following personal protective equipment (PPE) should the nurse instruct the client to wear?

7 :
A nurse is reinforcing teaching with a client about the prevention of deep vein thrombosis DVT). Which of the following recommendations should the nurse include in the teaching? (Select All that Apply.)

8 :
A nurse is reinforcing education provided to a client who has HIV about the infection process. Which of the following features of the virus should the nurse explain can result in opportunistic infection?

9 :
A nurse is reinforcing dietary teaching to a client who has a new onset of vitamin Bl 2 deficiency. Which of the following foods should the nurse encourage the client to include in their diet? (Select All that Apply.)

10 :
A nurse is assisting with the care of a client who has developed pulmonary embolism (PE). Which of the following diagnostic tests should the nurse anticipate the provider to prescribe to confirm the clients condition? (Select All that Apply.)