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NUR233 Exam 2- Davis With Complete Solution
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NUR233 Exam 2- Davis With Complete Solution2024-2025
You enter the room of a 75-year-old male client, Bob, admitted with a diagnosis of left
femur fracture who is in skeletal traction. Bob fell off a ladder at his home. He is going
into surgery in 12 hours for an open reduction internal fixation of the fracture. The nurse
considers Virchow's triad of risk factors for the development of a venous thrombosis.
Which factors does Bob have? Choose all that apply. - ANSWER Blood flow stasis,
Vessel wall injury
The Virchow's triad includes blood flow with decreased flow, injury to the endothelium,
and hypercoagulability. The client has blood stasis from immobility due to the injury and
blood vessel injury from the fracture. There is no history that would suggest he is at risk
for hypercoagulability-increased clotting of the blood.
Which of the following is not a risk factor for developing DVT?
A) Client's age
B) Client's gender
C) Client's immobility
D) Client's history of traumatic injury
ANSWER gender
You are finishing the shift evaluation of Bob. He states that the right calf, underneath the
SCD, is sore and moderately painful. You lightly palpate the right calf and observe
hardening along the blood vessel and that the skin is warmer compared to the left calf.
What does the nurse do next?
Visual inspect
Lightly massage the left calf.
Perform ROM exercises with the client.
, Medication review-reinstate based on a visual assessment
A complete assessment must be completed before notifying the provider. The provider
should visualize the problem themselves. You would not massage the leg, nor would you
do ROM with the client. Both are incorrect nursing interventions. You could review the
medication list, but that would not be your first course of action.
You remove Bob's sequential compression device (SCD) from the right leg to continue
the examination. Which of the following findings is of most concern?
A positive Homan's sign
Discoloration and redness to the right calf
Dry, flaky skin
A large dark mole on the tibia - ANSWER Discoloration and redness to the right calf
A DVT of the calf is typically purple and red in color and requires further diagnostic
study. A positive Homan's sign is an unreliable predictor and is therefore not
recommended. The integrity of the skin is not the concern at this point.
Your turn icon
At the conclusion of the exam, what do you do with the SCD?
Reinstitute the SCD on the client because the health-care provider did not cancel the
order.
Do not reinstate the SCD because the compression has the potential to dislodge a blood
clot.
Ask the client if he would like the SCD reinstated
Ask the charge nurse if the SCD should be reinstated back on the right leg and follow his
or her directions. - ANSWER Do not replace the SCD because the compression could
potentially dislodge a blood clot.
The SCD should not be replaced on the client's right leg due to the chance it may
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