Difficulty: Medium
Average Score: 84%
Simulated
Passage / Scenario
Question 166: Report an IssueReport Wrong AnswerNurses' notes
History and Physical
Vital signs
Today 0700:
Received change of shift report. Client is 2 days postoperative following a hysterectomy and they have not yet ambulated with physical therapy due to significant postoperative pain. Per change of shift report, pain medications have been adjusted and pain has improved. Client currently reports pain level as 2 on a scale of 0 to 10.
0900:
Ambulating in hallway with the assistance of physical therapy. 1000:
Return to bed with siderails up x 2, but not wearing sequential compression devices because they "hurt too much." Applied antiembolism stockings.
1400:
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct answer
A,D,E,C
Rationale
To determine the correct answer, we need to consider the condition the client is most likely experiencing, the actions the nurse should take, and the parameters to monitor.
- Deep vein thrombosis is a serious condition that requires prompt intervention.
- The nurse should monitor the client's BNP levels (D) to assess heart failure, which can be a complication of DVT.
- Monitoring for signs of bleeding after anticoagulation initiation (E) is crucial in DVT management.
- Checking the client's temperature (C) can help detect any signs of infection like cellulitis.
- Thus, the correct answer is A,D,E,C.
The other choices are incorrect because they do not align with the specific condition of DVT and the corresponding actions and parameters to monitor.
- Deep vein thrombosis is a serious condition that requires prompt intervention.
- The nurse should monitor the client's BNP levels (D) to assess heart failure, which can be a complication of DVT.
- Monitoring for signs of bleeding after anticoagulation initiation (E) is crucial in DVT management.
- Checking the client's temperature (C) can help detect any signs of infection like cellulitis.
- Thus, the correct answer is A,D,E,C.
The other choices are incorrect because they do not align with the specific condition of DVT and the corresponding actions and parameters to monitor.