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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Custom Adult Hlth I Hematology and Immune Test I

No.

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.)

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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

Custom Adult Hlth I Hematology and Immune Test I

No.

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.)