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RN101 Question Bank
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Deep Vein Thrombosis (16 Questions)
1. M. Jacques Tremblay, 68 years old, is recovering from a total hip replacement surgery performed 3 days ago. He calls the nurse complaining of a "cramping" pain in his right calf. Upon assessment, the nurse notes that the right calf circumference is 3 cm larger than the left, and the skin is warm and slightly red.
Question:
What does the nurse suspect is occurring?
*
Deep Vein Thrombosis (DVT).
Arterial Occlusion.
Post-operative wound infection (Cellulitis).
Normal post-surgical edema.
2. Mme. Marie-Eve Gagnon, 45 years old, is hospitalized for pneumonia and is on bed rest with bathroom privileges. She has a BMI of 35. The nurse is planning care to prevent venous thromboembolism (VTE).
Question:
Which nursing intervention is contraindicated (should be avoided) for DVT prevention?
*
Encouraging the patient to flex and extend her ankles (foot pumps) every hour.
Ensuring adequate fluid intake to prevent dehydration/hemoconcentration.
Placing a pillow firmly under the knees to prevent the patient from sliding down in bed.
Applying graduated compression stockings (TED hose) as ordered.
3. M. Luc Dubois, 58 years old, is receiving a continuous IV infusion of Unfractionated Heparin for a confirmed DVT in the left femoral vein. The protocol indicates a therapeutic range of 46–70 seconds for the aPTT. The laboratory calls with the latest aPTT result: 110 seconds.
Question:
What is the nurse’s priority action?
*
Continue the infusion at the current rate; this is an expected therapeutic level.
Stop the heparin infusion for the designated time per protocol and notify the provider.
Increase the infusion rate to ensure the clot dissolves.
Administer Vitamin K IM immediately.
4. Mme. Claire Fortin, 72 years old, has been on IV Heparin for 3 days for a DVT. The physician writes an order to start Warfarin (Coumadin) 5 mg PO daily. Mme. Fortin asks, "Why am I taking two blood thinners? Isn't that dangerous?"
Question:
What is the best explanation by the nurse?
*
"The Warfarin helps the Heparin work faster to dissolve the clot."
"It was likely a mistake; I will hold the Heparin and just give the pill."
"Warfarin takes several days to reach full effect."
"You will need to be on both medications for the rest of your life."
5. M. Antoine Cote, 60 years old, is diagnosed with an acute DVT in the right calf. He is started on anticoagulation therapy. His wife asks, "My husband’s leg hurts. Should I massage it to help the circulation?"
Question:
What is the most critical teaching point the nurse must provide?
*
"Yes, massage the leg vigorously for 10 minutes to reduce swelling."
"Apply ice packs followed by deep tissue massage."
"Never massage the affected leg, as this could cause the clot to break loose and travel to the lungs."
"Only massage the leg if he has taken his pain medication first."
6. Mme. Isabelle Poirier, 50 years old, is being treated for DVT. She suddenly rings the call bell. When the nurse arrives, Mme. Poirier is clutching her chest, gasping for air, and appears terrified. Her heart rate is 120 bpm, and SpO2 is 88%.
Question:
What is the nurse’s priority intervention?
*
Check the patient’s Homan’s sign.
Elevate the head of the bed (High-Fowler’s) and administer Oxygen.
Administer a PRN sedative to calm the patient’s anxiety.
Lay the patient flat and elevate the legs to treat shock.
7. M. Étienne Bouchard, 65 years old, is being discharged on Warfarin (Coumadin) for 6 months following a DVT. The nurse is providing dietary teaching regarding Vitamin K.
Question:
Which statement by M. Bouchard indicates a correct understanding of the teaching?
*
"I must completely eliminate all green leafy vegetables from my diet."
"I can eat as much spinach and kale as I want because they are healthy."
"I should try to keep my intake of green vegetables consistent from day to day."
"If I eat a salad, I should skip my Warfarin dose for that day."
8. Mme. Valérie Lavoie, 44 years old, has been on Heparin therapy for 5 days. The nurse reviews her morning labs.
Day 1 Platelet count: 250,000/mm³
Day 5 Platelet count: 90,000/mm³
Question:
What condition should the nurse suspect, and what is the required action?
*
Normal side effect of Heparin; document and continue.
Heparin Induced Thrombocytopenia (HIT); stop Heparin and notify physician immediately.
Anemia; request an order for Iron supplements.
Infection; check the white blood cell count.
9. Mme. Geneviève St-Laurent, 30 years old, presents to the clinic with left calf swelling and pain. She has no history of trauma. During the health history interview, the nurse identifies risk factors for DVT (Virchow’s Triad).
Question:
Which combination of factors places this patient at the highest risk for DVT?
*
She is a vegetarian and takes Vitamin C supplements.
She smokes one pack of cigarettes per day and takes oral contraceptives.
She jogs 5 km three times a week.
She works as a librarian and drinks 2 cups of coffee daily.
10. M. Patrick Roy, 75 years old, visits the anticoagulation clinic for his routine INR check. He is taking Warfarin for a recurrent DVT. His INR result is 2.5.
Question:
What is the appropriate nursing action based on this result?
*
Instruct the patient to go to the Emergency Department immediately.
Tell the patient to skip tonight's dose because the blood is too thin.
Instruct the patient to continue the current dosage; this is within the therapeutic range.
Tell the patient to double the dose because the blood is too thick.
11. M. Roch Voisine, 55 years old, is being treated for a DVT. The physician orders Enoxaparin (Lovenox) subcutaneous injections instead of an IV Unfractionated Heparin drip. M. Voisine asks, "Why is this injection better than the IV drip my father had years ago?"
Question:
What is the most accurate information the nurse can provide regarding the advantage of Enoxaparin (Low-Molecular-Weight Heparin)?
*
"Enoxaparin dissolves the clot immediately, whereas Heparin only prevents new ones."
"Enoxaparin has a lower risk of bleeding than Heparin, so we don't need to watch you as closely."
"Enoxaparin has a more predictable absorption and effect, so frequent blood tests (aPTT) are not required."
"Enoxaparin is less painful to administer than an IV infusion."
12. M. Félix Leclerc, 70 years old, has been stable on Warfarin (Coumadin) for 3 months with an INR of 2.5. He tells the nurse, "I decided to get healthy. For the last week, I have been drinking 3 cups of Matcha Green Tea and eating a large bowl of Broccoli for lunch every day."
Question:
Based on this dietary change, what clinical change should the nurse anticipate?
*
The INR will likely increase, placing him at risk for bleeding.
The INR will likely decrease, placing him at risk for developing a new clot.
The INR will remain unchanged as vegetables are healthy.
The Warfarin will become toxic and cause liver failure.
13. Mme. Julie Payette, 62 years old, is newly prescribed Warfarin (Coumadin). During the nutritional assessment, she mentions, "I always start my day with a large glass of freshly squeezed grapefruit juice."
Question:
What is the priority nursing instruction?
*
"That is excellent; the Vitamin C will help strengthen your blood vessels."
"You can continue drinking it, but you must take your medication 2 hours later."
"You should avoid grapefruit juice, as it can interfere with how your liver processes the medication and increase your risk of bleeding."
"You should switch to cranberry juice, as it is safer for your kidneys."
14. M. Jean Béliveau, 78 years old, is being discharged on long-term anticoagulant therapy. The nurse is reviewing "Bleeding Precautions" to prevent injury during Activities of Daily Living (ADLs).
Question:
Which statement by M. Béliveau indicates that the teaching has been effective?
*
"I will use a straight razor for shaving to get a clean shave without pressing too hard."
"I will stop flossing my teeth to prevent my gums from bleeding."
"I will usually walk barefoot in the house to keep from tripping over slippers."
"I will switch to an electric razor and use a soft-bristle toothbrush."
15. The nurse is teaching Mme. Karine Vanasse, 35 years old, how to self-administer Enoxaparin (Lovenox) at home for DVT prophylaxis. The nurse observes Mme. Vanasse preparing the pre-filled syringe. Mme. Vanasse says, "I see a little air bubble in the syringe. I should push that out before I inject, right?"
Question:
What is the correct nursing response?
*
"Yes, always expel air to prevent an air embolism."
"It does not matter if you leave it or remove it."
"You should tap the syringe until the bubble moves to the bottom, then inject."
"No, do not expel the air bubble. It is there to ensure you get the full dose and to seal the medication in the tissue."
16. M. Serge Bouchard, 48 years old, is a long-haul truck driver who frequently travels from Montréal to Vancouver (a drive taking several days). He was treated for a DVT two years ago. He visits the clinic for a check-up before his next trip. He asks the nurse, "I have to sit in the driver's seat for 10 to 12 hours a day to make my delivery times. How can I stop the clot from coming back?"
Question:
What is the most appropriate teaching the nurse should provide regarding his travel routine?
*
"Limit your fluid intake during the day so you do not have to stop frequently for the bathroom."
"Take two Aspirins (ASA) 325 mg before you start driving to thin your blood."
"Stop the truck every 2 to 3 hours to get out and walk for 10 minutes, and wear your prescribed compression stockings while driving."
"Adjust your seat so your knees are higher than your hips to promote venous return."