Question

Nurse is providing teaching to 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.)

Answer 1

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 can restrict venous return, increasing the risk of venous stasis, a major risk factor for DVT.

🔴Patients should maintain neutral leg positioning while sitting.

Move frequently while on an airplane

🔴Prolonged sitting during travel reduces venous return in the lower extremities.

🔴Patients should stretch, walk, and perform calf exercises during long flights to reduce DVT risk.

Discontinue estrogen therapy if your medical provider recommends

🔴Estrogen therapy (oral contraceptives or hormone replacement) increases the risk of hypercoagulability.

🔴Stopping estrogen when appropriate reduces DVT risk.

Stop smoking and avoid secondhand smoke

🔴Smoking increases blood viscosity and platelet aggregation, promoting thrombosis.

🔴Cessation of smoking is a preventive strategy for DVT.

❌Reduce ambulation after a surgery

🔴Immobility increases DVT risk due to venous stasis.

🔴Patients are encouraged to ambulate as soon as safely possible postoperatively to prevent clot formation.

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Answer 2

Correct Answers:

Worsening thrombocytopenia

Rationale :

Worsening thrombocytopenia

💊Romiplostim is a thrombopoietin receptor agonist that stimulates the bone marrow to produce platelets.

💊If platelet counts decrease instead of increasing, this indicates the medication is ineffective or causing adverse effects, such as antibody formation or marrow suppression.

💊This is a serious concern in clients with chemotherapy-induced thrombocytopenia (CIT) and requires discontinuation and provider notification.

❌ Increased appetite

💊Mild appetite changes may occur with chemotherapy or supportive medications, but this is not life-threatening and does not require discontinuation of romiplostim.

❌ Nausea and vomiting

💊These are common, manageable side effects of many chemotherapy-related medications.

💊Symptomatic management (antiemetics, hydration) is appropriate; medication discontinuation is not required.

❌ Hair thinning

💊Hair loss is a common effect of chemotherapy itself, not romiplostim.

💊It does not necessitate stopping the medication.

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Answer 3

Correct Answers:

Worsening thrombocytopenia

Rationale :

Worsening thrombocytopenia

💠Romiplostim is a thrombopoietin receptor agonist used to stimulate platelet production in chemotherapy-induced thrombocytopenia (CIT).

💠If platelet counts continue to fall or do not improve, it indicates that the medication is ineffective or causing adverse reactions.

💠This requires discontinuation of the medication and immediate notification of the healthcare provider to prevent serious bleeding complications.

❌ Increased appetite

💠Appetite changes can occur with cancer treatment or supportive medications but are not dangerous and do not require stopping romiplostim.

❌Nausea and vomiting

💠These are common and expected side effects with cancer therapy or supportive medications.

💠Management typically involves antiemetics, and discontinuation is not needed.

❌Hair thinning

💠Hair loss or thinning is usually a result of chemotherapy, not romiplostim.

💠It is not a reason to stop the medication.

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Answer 4

Correct Answers:

Repeat blood serum potassium
.Educate client regarding high-potassium food sources
Cardiac monitoring during infusion
Ensure that the client's urine output is at least 1 mL/kg/hour

Rationale :

Repeat blood serum potassium

▶️Potassium levels should be rechecked before and during replacement therapy to ensure the client is actually hypokalemic and to monitor correction.

▶️Prevents overcorrection and hyperkalemia, which can be dangerous.

Educate client regarding high-potassium food sources

▶️Oral potassium supplementation and dietary education help maintain potassium balance long-term.

▶️Examples: bananas, oranges, potatoes, leafy greens.

Cardiac monitoring during infusion

▶️Hypokalemia can cause arrhythmias.

▶️IV potassium must be administered slowly and monitored; continuous cardiac monitoring is recommended for severe hypokalemia (<3.0 mEq/L).

Ensure that the client's urine output is at least 1 mL/kg/hour

▶️Adequate urine output indicates renal function is sufficient to excrete potassium safely.

▶️Helps prevent hyperkalemia and monitor for complications during IV potassium therapy.

❌Ensure potassium infusion is prepared with 5% dextrose solution

▶️Dextrose-containing solutions stimulate insulin release, which can drive potassium into cells, potentially worsening hypokalemia.

▶️Use normal saline (0.9% NaCl) as the preferred IV fluid for potassium replacement.

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Answer 5

Correct Answers:

Hypotension
Diaphoresis
Tachypnea

Rationale :

Hypotension

❇️Acute blood loss decreases circulating volume, leading to low blood pressure.

❇️Hypotension is a classic early sign of hemorrhage, especially postoperatively.

Diaphoresis

❇️As the body tries to compensate for decreased perfusion, the sympathetic nervous system is activated.

❇️This causes sweating (diaphoresis), pallor, and cool, clammy skin.

Tachypnea

❇️Rapid breathing occurs as a compensatory mechanism to improve oxygen delivery when blood volume and oxygen-carrying capacity are reduced.

❌ Bradycardia

❇️Early hemorrhage typically causes tachycardia, not bradycardia.

❇️Bradycardia may occur in late or severe hemorrhage as a pre-terminal sign.

❌Diarrhea

❇️Diarrhea is not a direct sign of hemorrhage.

❇️It may be related to medications or GI irritation but does not indicate blood loss.

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Answer 6

Correct Answers:

To increase platelet function in a client with uremic platelet dysfunction
To manage frequent nighttime urination in pediatric clients
To distinguish between central and nephrogenic diabetes insipidus

Rationale :

To increase platelet function in a client with uremic platelet dysfunction

✍️Desmopressin (DDAVP) promotes the release of von Willebrand factor (vWF) and factor VIII from endothelial cells.

✍️It is used to improve platelet adhesion and clotting in conditions like uremic platelet dysfunction and mild type 1 and 2 von Willebrand disease.

To manage frequent nighttime urination in pediatric clients

✍️DDAVP has an antidiuretic effect by increasing water reabsorption in the kidneys.

✍️It is indicated for nocturnal enuresis (bedwetting) in children.

To distinguish between central and nephrogenic diabetes insipidus

✍️RDDAVP reduces urine output in central DI (deficiency of ADH) but not in nephrogenic DI (kidney resistance to ADH).

✍️It is used as a diagnostic tool to differentiate the two types.

❌To treat a client who has type 3 von Willebrand disease

✍️Type 3 vWD involves severe deficiency of vWF.

✍️DDAVP is ineffective because there is little or no vWF to release, so treatment requires vWF concentrates.

❌To reduce the risk of thrombus formation with atrial fibrillation

✍️DDAVP is not an anticoagulant.

✍️It increases clotting factors and would actually increase risk of thrombus formation, making it inappropriate for AFib prevention.

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Answer 7

Correct Answers:

A new-onset headache

Rationale :

A new-onset headache

▶️Lusutrombopag is a thrombopoietin receptor agonist used to increase platelet counts in clients with bone marrow suppression.

▶️A new headache can indicate thromboembolic complications (e.g., cerebral thrombosis), which is a serious and potentially life-threatening adverse effect.

❌Fatigue and weakness

▶️Fatigue and weakness are common baseline symptoms in clients with bone marrow suppression or chronic illness.

▶️While important to monitor, these do not require immediate intervention.

❌Increased appetite

▶️Increased appetite is a benign side effect and is not associated with urgent complications of lusutrombopag.

❌ Mild constipation

▶️Mild constipation may occur with medications or reduced activity, but it is not life-threatening and does not require urgent reporting.

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Answer 8

Correct Answers:

Respiratory acidosis partially compensated

Rationale :

Respiratory acidosis, partially compensated

⭐ABG Values Provided:

pH: 7.25 (normal 7.35–7.45) → acidotic
PaCO₂: 50 mmHg (normal 35–45 mmHg) → elevated, indicates respiratory origin
HCO₃⁻: 30 mEq/L (normal 22–26 mEq/L) → elevated, indicates metabolic compensation

⭐ Identify the primary disturbance

Acidosis (pH <7.35) → body is acidotic
PaCO₂ elevated → lungs are retaining CO₂ → respiratory acidosis

⭐ Assess compensation

HCO₃⁻ is elevated → kidneys are retaining bicarbonate to compensate.
pH is still below 7.35 → compensation is partial, not complete.

❌Respiratory alkalosis

⭐ PaCO₂ would be low (<35 mmHg).

❌Fully compensated respiratory acidosis

⭐ pH would be in the normal range (7.35–7.45).

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Answer 9

Correct Answers:

The client has not experienced any new episodes of thrombosis since starting the medication.

Rationale :

The client has not experienced any new episodes of thrombosis

👉Clopidogrel is an antiplatelet medication used to prevent platelet aggregation, reducing the risk of blood clots (thrombosis).

👉After a percutaneous coronary intervention (PCI), the desired therapeutic effect is the prevention of stent thrombosis, myocardial infarction, or other clotting events.

👉Absence of new thrombotic events indicates the medication is effectively reducing clot formation.

❌The client reports complete relief of pain from chronic stable angina

👉Clopidogrel does not relieve angina pain.

👉Angina pain is managed with nitrates, beta-blockers, or calcium channel blockers, not antiplatelet therapy.

❌The client's cholesterol levels have significantly decreased

👉Clopidogrel does not affect cholesterol.

👉Lipid levels are managed with statins or other lipid-lowering agents.

❌The client's blood pressure has remained within the expected range

👉Blood pressure control is not a direct effect of clopidogrel.

👉Hypertension is managed separately with antihypertensives.

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Answer 10

Correct Answers:

A client with liver disease presenting with hematemesis and signs of hypovolemic shock

Rationale :

Client with liver disease, hematemesis, and hypovolemic shock

🙌Hematemsis in a client with liver disease suggests variceal bleeding, which can be life-threatening.

🙌Signs of hypovolemic shock (low blood pressure, tachycardia, cool/clammy skin, altered mental status) indicate active, significant blood loss.

🙌This is a priority emergency and requires immediate assessment and intervention to stabilize the patient.

❌Client with history of DVT reporting mild leg pain

🙌Mild pain is non-urgent compared to active hemorrhage.

🙌This client should be monitored but does not require immediate life-saving intervention.

❌Client with suspected hemophilia with a responding nosebleed

🙌The nosebleed is controlled with pressure, indicating bleeding is not severe.

🙌Although bleeding disorders increase risk, this client is stable.

❌ Client with HIT and minor injection site bleeding

🙌Minor bleeding at the injection site is not immediately life-threatening.

🙌Monitor for worsening bleeding or platelet drop, but this is not as urgent as active massive bleeding.

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Custom SP26 Sec 2 Exam 3 Blandon

No.

1 : Nurse is providing teaching to 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.)

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

❌Reduce ambulation after a surgery

2 : Nurse is reviewing the medication profile of a client receiving romiplostim for chemotherapy-induced thrombocytopenia (CIT). Which of the following adverse effects should the nurse recognize as a reason to discontinue the medication and notify the provider?

Worsening thrombocytopenia

❌ Increased appetite

❌ Nausea and vomiting

❌ Hair thinning

3 : Nurse is reviewing the medication profile of a client receiving romiplostim for chemotherapy-induced thrombocytopenia (CIT). Which of the following adverse effects should the nurse recognize as a reason to discontinue the medication and notify the provider?

Worsening thrombocytopenia

❌ Increased appetite

❌Nausea and vomiting

❌Hair thinning

4 : Nurse is preparing to administer prescribed intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L (3.5 to 5 mEq/L). Which of the following actions should the nurse plan to include? (Select All that Apply.)

Repeat blood serum potassium

Educate client regarding high-potassium food sources

Cardiac monitoring during infusion

Ensure that the client's urine output is at least 1 mL/kg/hour

❌Ensure potassium infusion is prepared with 5% dextrose solution

5 : Nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage? (Select All that Apply.)

Hypotension

Tachypnea

❌ Bradycardia

❌Diarrhea

6 : A nurse is reviewing the use of desmopressin with a client who has von Willebrand disease. Which of the following situations should the nurse identify as appropriate indications for the use of desmopressin? (Select All that Apply.)

To increase platelet function in a client with uremic platelet dysfunction

To manage frequent nighttime urination in pediatric clients

To distinguish between central and nephrogenic diabetes insipidus

❌To treat a client who has type 3 von Willebrand disease

❌To reduce the risk of thrombus formation with atrial fibrillation

7 : A nurse is assessing a client who has been receiving lusutrombopag for the management of bone marrow suppression induced by antiviral therapies. Which of the following findings should the nurse prioritize and report to the provider?

A new-onset headache

❌Fatigue and weakness

❌Increased appetite

❌ Mild constipation

8 : A patient presents with a pH of 7.25, PaCO₂ of 50 mmHg, and HCO₃⁻ of 30 mEq/L. Which of the following best describes the ABG results?

⭐ABG Values Provided:

⭐ Identify the primary disturbance

⭐ Assess compensation

9 : A nurse is evaluating a client who has been prescribed clopidogrel following a percutaneous coronary intervention (PCI). Which of the following outcomes should indicate to the nurse that the medication is achieving the desired therapeutic effect?

The client has not experienced any new episodes of thrombosis

❌The client reports complete relief of pain from chronic stable angina

❌The client's cholesterol levels have significantly decreased

❌The client's blood pressure has remained within the expected range

10 : A nurse is caring for four clients with potential coagulation disorders. Which of the following clients should the nurse assess first?

Client with liver disease, hematemesis, and hypovolemic shock

❌Client with history of DVT reporting mild leg pain

❌Client with suspected hemophilia with a responding nosebleed

❌ Client with HIT and minor injection site bleeding

1 :
Nurse is providing teaching to 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.)

2 :
Nurse is reviewing the medication profile of a client receiving romiplostim for chemotherapy-induced thrombocytopenia (CIT). Which of the following adverse effects should the nurse recognize as a reason to discontinue the medication and notify the provider?

3 :
Nurse is reviewing the medication profile of a client receiving romiplostim for chemotherapy-induced thrombocytopenia (CIT). Which of the following adverse effects should the nurse recognize as a reason to discontinue the medication and notify the provider?

4 :
Nurse is preparing to administer prescribed intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L (3.5 to 5 mEq/L). Which of the following actions should the nurse plan to include? (Select All that Apply.)

5 :
Nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage? (Select All that Apply.)

6 :
A nurse is reviewing the use of desmopressin with a client who has von Willebrand disease. Which of the following situations should the nurse identify as appropriate indications for the use of desmopressin? (Select All that Apply.)

7 :
A nurse is assessing a client who has been receiving lusutrombopag for the management of bone marrow suppression induced by antiviral therapies. Which of the following findings should the nurse prioritize and report to the provider?

8 :
A patient presents with a pH of 7.25, PaCO₂ of 50 mmHg, and HCO₃⁻ of 30 mEq/L. Which of the following best describes the ABG results?

9 :
A nurse is evaluating a client who has been prescribed clopidogrel following a percutaneous coronary intervention (PCI). Which of the following outcomes should indicate to the nurse that the medication is achieving the desired therapeutic effect?

10 :
A nurse is caring for four clients with potential coagulation disorders. Which of the following clients should the nurse assess first?