Question

A nurse is caring for a client who is postoperative following a total knee replacement. Which of the following actions should the nurse implement to prevent deep vein thrombophlebitis?

Answer 1

Correct Answers:

Encourage increased fluid intake.

Rationale :

💧 Adequate hydration helps prevent hemoconcentration, which reduces blood viscosity and lowers the risk of clot formation after surgery.

💧 Postoperative clients are at high risk for DVT due to venous stasis, surgical trauma, and reduced mobility, making fluid balance a key preventive measure.

💧 Increasing fluid intake supports optimal circulation, promoting smoother venous blood flow from the lower extremities.

💧 Proper hydration also enhances renal perfusion, helping eliminate metabolic waste products that may contribute to clotting risk.

💧 This intervention is safe, noninvasive, and complements other DVT prevention strategies such as early ambulation and compression devices.

❌ Incorrect Options

🚫 Keep the affected knee flexed.

Keeping the knee flexed promotes venous stasis, which slows blood return and increases the risk of clot formation. Postoperative positioning should encourage extension and circulation, not flexion.

🚫 Massage the client’s calf on the affected side.

Massaging the calf can dislodge an existing clot, potentially leading to a pulmonary embolism. This action is contraindicated when DVT risk is present.

🚫 Promote bed rest for 5 days.

Prolonged immobility significantly increases the risk of venous pooling and thrombosis. Early and progressive mobilization is essential after orthopedic surgery.

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Answer 2

Correct Answers:

Keep dedicated equipment in the client's room.

Rationale :

🧬 Clients with neutropenia have a significantly reduced ability to fight infections, making strict infection-control measures essential.

🧬 Keeping dedicated equipment in the client’s room prevents cross-contamination from shared devices such as blood pressure cuffs or thermometers.

🧬 This intervention directly reduces exposure to environmental and contact-borne pathogens, which can be life-threatening in immunocompromised clients.

🧬 It supports protective (reverse) isolation, a core principle in neutropenic care.

🧬 This strategy works alongside hand hygiene and environmental controls to minimize infection risk.

❌ Incorrect Options

🚫 Use a nasal cannula to administer oxygen at 2 L/min.

Oxygen administration does not address infection prevention unless hypoxia is present. A nasal cannula also introduces a potential route for microbial entry if not indicated.

🚫 Restrict visitors.

Visitor restriction may be used selectively, but it is not always required and should be based on infection risk assessment. The question asks for a core intervention specific to neutropenia care.

🚫 Monitor level of consciousness every 4 hr.

Neurological monitoring is not directly related to neutropenia management. Infection prevention takes priority over routine neurologic checks.

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Answer 3

Correct Answers:

"Our child's blood count will need to be monitored routinely for several weeks."

Rationale :

💊 Iron therapy is used to correct iron-deficiency anemia, and its effectiveness must be evaluated through serial laboratory monitoring.

💊 Monitoring blood counts allows providers to assess hemoglobin response and ensure appropriate dosing.

💊 Routine labs also help detect iron overload or inadequate absorption, especially in pediatric clients.

💊 Iron supplementation is typically required for several weeks to months, making follow-up essential.

💊 This statement reflects correct understanding of treatment duration and safety monitoring.

❌ Incorrect Options

🚫 “The medication should be administered in one large dose per day.”

Iron is better absorbed and tolerated when given in divided doses. Large single doses increase gastrointestinal irritation.

🚫 “The medication will be more effective if it is administered with meals.”

Iron absorption is reduced when taken with food. It is most effective when taken on an empty stomach unless GI upset occurs.

🚫 “Restricting fiber from our child’s diet will help with iron absorption.”

Fiber does not significantly impair iron absorption to require restriction. Balanced nutrition should be maintained.

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Answer 4

Correct Answers:

Edema

Rationale :

🦵 Thrombophlebitis causes venous inflammation and clot formation, which obstructs venous return.

🦵 This obstruction leads to fluid accumulation in the affected limb, resulting in localized edema.

🦵 Swelling is often accompanied by warmth and tenderness due to inflammatory processes.

🦵 Edema reflects impaired circulation rather than arterial compromise.

🦵 This finding is a classic and expected manifestation of venous thrombosis.

❌ Incorrect Options

🚫 Numbness

Numbness is more commonly associated with neurological compromise, not venous inflammation. Thrombophlebitis primarily affects circulation, not nerve conduction.

🚫 Cool skin

Cool skin suggests arterial insufficiency, not venous obstruction. Thrombophlebitis typically presents with warmth.

🚫 Pallor

Pallor is linked to reduced arterial blood flow. Venous disorders usually cause redness and swelling instead.

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Answer 5

Correct Answers:

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

Rationale :

🫁 D-dimer blood test

🫁 The D-dimer test detects fibrin degradation products, which increase when a blood clot is actively forming and breaking down in the body.

🫁 In clients with suspected pulmonary embolism, an elevated D-dimer supports the possibility of a thromboembolic event.

🫁 This test is especially useful to rule out PE in low-risk clients when the result is normal.

🫁 A positive result does not confirm PE on its own but signals the need for further imaging.

🫁 It is a rapid, minimally invasive screening tool that guides next diagnostic steps.

🫁 CT scan (CT pulmonary angiography)

🫁 A CT pulmonary angiography is the gold-standard diagnostic test for confirming pulmonary embolism.

🫁 It provides direct visualization of clots within the pulmonary arteries, allowing precise localization.

🫁 This imaging modality also helps assess the extent of obstruction and strain on the right side of the heart.

🫁 It is fast, highly sensitive, and commonly used in acute care settings.

🫁 CT imaging allows providers to rapidly confirm PE and initiate lifesaving treatment.

🫁 Lung ventilation and perfusion (V/Q) scan

🫁 A V/Q scan evaluates the relationship between airflow (ventilation) and blood flow (perfusion) in the lungs.

🫁 Pulmonary embolism causes perfusion defects while ventilation remains relatively normal, creating a mismatch.

🫁 This test is especially valuable when a client cannot receive contrast dye, such as in renal impairment or pregnancy.

🫁 A high-probability V/Q scan strongly supports the diagnosis of PE.

🫁 It remains an important alternative diagnostic tool when CT is contraindicated.

❌ Incorrect Options

🫁 Complete blood count (CBC)

A CBC may show nonspecific findings such as mild leukocytosis but cannot diagnose PE. It is used for general assessment, not confirmation of thromboembolism.

🫁 Chest x-ray

A chest x-ray is often normal in PE or shows nonspecific changes. It is mainly used to rule out other causes of respiratory distress, not to confirm PE.

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Answer 6

Correct Answers:

Inflammation and irritation on right calf
Warmth on right leg
4+ edema to right leg

Rationale :

🔴 Inflammation and irritation on right calf

🔴 Localized inflammation and irritation of the calf strongly suggest acute venous inflammation, a hallmark of developing deep vein thrombosis (DVT).

🔴 In a client with a spinal cord injury, immobility significantly increases venous stasis, making this finding especially concerning.

🔴 The presence of visible skin changes indicates active pathology, not a benign postoperative or dependent change.

🔴 When paired with escalating pain, this finding raises concern for clot formation rather than simple fluid accumulation.

🔴 Immediate follow-up is required because untreated DVT can progress rapidly to pulmonary embolism, a life-threatening complication.

🟠 Warmth on right leg

🟠 Increased warmth in one extremity reflects localized inflammatory response associated with venous thrombosis.

🟠 Unilateral warmth is abnormal and should never be attributed to positioning alone in high-risk clients.

🟠 Heat results from increased blood flow and inflammation around the affected vein.

🟠 In combination with swelling and pain, warmth strongly supports suspected DVT.

🟠 This finding requires urgent evaluation to prevent embolization of the clot.

🟣 4+ edema to right leg

🟣 Severe unilateral edema (4+) indicates significant venous obstruction, preventing normal blood return.

🟣 The rapid progression from 1+ to 4+ edema signals an acute and worsening condition, not chronic fluid retention.

🟣 Venous congestion causes fluid to shift into interstitial spaces, producing marked swelling.

🟣 This level of edema is a classic indicator of deep venous compromise.

🟣 Immediate follow-up is critical to prevent circulatory collapse or embolic events.

❌ Incorrect Options

⚪ Capillary refill less than 3 seconds in right great toe

Normal capillary refill indicates adequate arterial perfusion to the extremity. DVT is a venous disorder, so this finding is expected and not concerning.

⚪ Pedal pulses of right leg 3+

Strong pedal pulses confirm intact arterial circulation. DVT does not impair arterial flow, so this finding does not require follow-up.

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Answer 7

Correct Answers:

"You will need to take this medication for at least 6 to 12 months to prevent the reocclusion of your stent."

Rationale :

🔵 Antiplatelet therapy such as clopidogrel is essential after coronary stent placement to prevent platelet aggregation at the stent site.

🔵 Stents are foreign bodies that significantly increase the risk of acute and late thrombosis if antiplatelet therapy is stopped early.

🔵 Continuing therapy for 6 to 12 months allows the stent to become fully endothelialized, reducing clot risk.

🔵 Premature discontinuation is one of the leading causes of stent reocclusion and myocardial infarction.

🔵 Adhering to the prescribed duration is a critical, life-saving component of post-stent management.

❌ Incorrect Options

🔹 “Once you feel better, and manifestations improve, you can stop taking the medication.”

Symptoms improving does not mean the stent is safe from clot formation. Stopping early greatly increases the risk of sudden stent thrombosis.

🔹 “This medication is usually prescribed for a short duration of one-week post-surgery.”

One week is far too short for endothelial healing. Antiplatelet therapy must be continued for months, not days.

🔹 “The medication should be continued indefinitely for lifelong prevention of heart attacks and strokes.”

While some clients may need long-term antiplatelet therapy, clopidogrel after stent placement is not always lifelong. Duration depends on stent type and provider assessment.

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Answer 8

Correct Answers:

Hemoglobin of 6.2 g/dL in a client who is receiving chemotherapy

Rationale :

🟠 Severely low hemoglobin indicates critical anemia, which compromises oxygen delivery to tissues.

🟠 Clients receiving chemotherapy are already at risk for bone marrow suppression, making this finding especially dangerous.

🟠 A hemoglobin of 6.2 g/dL can lead to hypoxia, cardiac strain, and hemodynamic instability.

🟠 This level often requires urgent intervention, such as blood transfusion or therapy adjustment.

🟠 Immediate provider notification is necessary to prevent life-threatening complications.

❌ Incorrect Options

🔸 WBC of 7,000/mm³ in a client who has a non-productive cough

This value falls within the normal range. It does not indicate infection or hematologic compromise.

🔸 Red blood cells of 5 cells/µL

This value likely represents a urinalysis finding and is not critically abnormal. Mild hematuria alone does not require urgent reporting.

🔸 Platelet count of 160,000/mm³ in a client who has a DVT and is taking enoxaparin

This platelet level is within normal limits. It does not suggest bleeding risk or heparin-induced thrombocytopenia.

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Answer 9

Correct Answers:

Fatigue

Rationale :

🟢 Iron deficiency anemia results in decreased hemoglobin production, reducing oxygen delivery throughout the body.

🟢 Inadequate oxygenation causes cellular energy depletion, leading to persistent fatigue and weakness.

🟢 Fatigue is often the earliest and most common symptom reported by affected clients.

🟢 Clients may describe exercise intolerance, shortness of breath on exertion, and decreased stamina.

🟢 This symptom reflects the body’s inability to meet metabolic demands due to insufficient red blood cell function.

❌ Incorrect Options

🔻 Confusion

Confusion is more commonly associated with hypoxia from severe respiratory or neurologic disorders. It is not a primary finding in iron deficiency anemia.

🔻 Joint pain

Joint pain is unrelated to iron levels and suggests inflammatory or musculoskeletal conditions. It is not characteristic of anemia.

🔻 Slurred speech

Slurred speech indicates possible neurologic impairment or stroke. Iron deficiency anemia does not affect speech centers.

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Answer 10

Correct Answers:

Infection

Rationale :

🦠 Children with acute lymphoblastic leukemia (ALL) are at extremely high risk for infection due to bone marrow suppression that reduces functional white blood cells.

🦠 The disease process itself, along with chemotherapy, leads to neutropenia, impairing the body’s ability to mount an immune response.

🦠 Even minor infections can rapidly become life-threatening sepsis in immunocompromised pediatric clients.

🦠 Fever may be the only early sign of infection, requiring vigilant monitoring and prompt intervention.

🦠 Because infection is the leading cause of morbidity and mortality in children with ALL, it is the top nursing priority.

❌ Incorrect Options

🔹 Hyperglycemia

Hyperglycemia may occur secondary to steroid therapy, but it does not pose the same immediate life-threatening risk as infection. It is monitored routinely but is not the primary priority.

🔹 Hypocalcemia

Electrolyte imbalances can occur but are not the most common or urgent complication in ALL. They are typically secondary concerns unless severe.

🔹 Hypertension

Hypertension is not directly associated with ALL and does not reflect the primary danger posed by the disease. It may occur from medications but is not the priority complication.

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Custom MS Hematology Exam 626

No.

1 :
A nurse is caring for a client who is postoperative following a total knee replacement. Which of the following actions should the nurse implement to prevent deep vein thrombophlebitis?

❌ Incorrect Options

2 :
A nurse is assisting with the plan of care for a client who has neutropenia. Which of the following interventions should the nurse include in the plan of care?

❌ Incorrect Options

3 :
A nurse is reinforcing teaching with the parents of a child who is taking iron supplements. Which of the following statements by the parents indicates an understanding of the teaching?

❌ Incorrect Options

4 :
A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

❌ Incorrect Options

5 :
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 client's condition? (Select All that Apply.)

6 :
A nurse is caring for a client who has a spinal cord injury.

Answer Options

7 :
A nurse is reinforcing teaching with a client who has been prescribed an antiplatelet (such as clopidogrel) following the placement of a coronary stent. Which of the following statements should the nurse include regarding the duration of medication therapy???

8 :
A nurse is reviewing the laboratory results of a group of clients. Which of the following laboratory findings should the nurse report to the provider?

9 :
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?

10 :
When prioritizing care for a child with ALL, which complication should the nurse anticipate and monitor closely?

❌ Incorrect Options

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Custom MS Hematology Exam 626

No.

1 : A nurse is caring for a client who is postoperative following a total knee replacement. Which of the following actions should the nurse implement to prevent deep vein thrombophlebitis?

❌ Incorrect Options

2 : A nurse is assisting with the plan of care for a client who has neutropenia. Which of the following interventions should the nurse include in the plan of care?

❌ Incorrect Options

3 : A nurse is reinforcing teaching with the parents of a child who is taking iron supplements. Which of the following statements by the parents indicates an understanding of the teaching?

❌ Incorrect Options

4 : A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

❌ Incorrect Options

5 : 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 client's condition? (Select All that Apply.)

6 : A nurse is caring for a client who has a spinal cord injury.

Answer Options

7 : A nurse is reinforcing teaching with a client who has been prescribed an antiplatelet (such as clopidogrel) following the placement of a coronary stent. Which of the following statements should the nurse include regarding the duration of medication therapy???

8 : A nurse is reviewing the laboratory results of a group of clients. Which of the following laboratory findings should the nurse report to the provider?

9 : A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?

10 : When prioritizing care for a child with ALL, which complication should the nurse anticipate and monitor closely?

❌ Incorrect Options

1 :
A nurse is caring for a client who is postoperative following a total knee replacement. Which of the following actions should the nurse implement to prevent deep vein thrombophlebitis?

2 :
A nurse is assisting with the plan of care for a client who has neutropenia. Which of the following interventions should the nurse include in the plan of care?

3 :
A nurse is reinforcing teaching with the parents of a child who is taking iron supplements. Which of the following statements by the parents indicates an understanding of the teaching?

4 :
A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

5 :
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 client's condition? (Select All that Apply.)

6 :
A nurse is caring for a client who has a spinal cord injury.

7 :
A nurse is reinforcing teaching with a client who has been prescribed an antiplatelet (such as clopidogrel) following the placement of a coronary stent. Which of the following statements should the nurse include regarding the duration of medication therapy???

8 :
A nurse is reviewing the laboratory results of a group of clients. Which of the following laboratory findings should the nurse report to the provider?

9 :
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?

10 :
When prioritizing care for a child with ALL, which complication should the nurse anticipate and monitor closely?