Nursing Fundamentals & Patient Care Flashcards

Which finding is a classic sign of deep vein thrombosis (DVT) in the lower extremity?

Answer: Unilateral calf pain, warmth, redness, and swelling

DVT classically presents with unilateral signs because the clot forms in one leg's vein. The triad of pain, warmth, and swelling results from venous obstruction and inflammation. Homan's sign is unreliable; Doppler ultrasound confirms diagnosis.

A postoperative patient develops sudden onset chest pain and dyspnea. Which complication is most likely?

Answer: Pulmonary embolism

Sudden onset pleuritic chest pain with dyspnea in a postoperative patient is the classic presentation of pulmonary embolism, often caused by dislodgment of a DVT. This is a life-threatening emergency requiring immediate action.

What is the recommended frequency for repositioning an immobile patient to prevent pressure injuries?

Answer: Every 2 hours

Evidence-based guidelines recommend repositioning every 2 hours for immobile patients to relieve pressure over bony prominences. For patients on high-specification foam mattresses, a 4-hour schedule may be appropriate, but 2 hours is the standard.

Which laboratory value indicates a patient is at high risk for bleeding?

Answer: Platelet count of 40,000/μL

A platelet count below 50,000/μL significantly increases bleeding risk. Normal platelet count is 150,000–400,000/μL. At 40,000/μL, spontaneous bleeding can occur and invasive procedures should be approached cautiously.

A nurse is preparing to administer a blood transfusion. Which action is the highest priority before starting?

Answer: Verify patient identity and blood product compatibility at the bedside with two nurses

Two-nurse verification of patient identity (using two identifiers) and blood product compatibility (ABO/Rh type, unit number, expiration) is mandatory before any transfusion to prevent potentially fatal hemolytic transfusion reactions.

What is the correct procedure for documenting a medication administration error?

Answer: Complete an incident report and document objectively in the patient's chart; do not write 'error' in the chart

The incident report is an internal quality improvement tool separate from the medical record. The chart should reflect objective clinical facts (what was given, patient response, physician notification) without the word 'error,' which is a legal term.