Today’s NCLEX-RN® question of the day focuses on a nurse tending to a patient with deep vein thrombosis (DVT) in the left lower extremity. Which potential complication should the nurse identify as a priority? Can you figure it out?
The nurse in the intermediate care unit is caring for a patient with deep vein thrombosis (DVT) in the left lower extremity. The nurse should recognize which potential complication as a priority?
A. Unsteady gait with ambulation
B. Acute pain in the left lower leg
C. Formation of a venous stasis ulcer
D. Development of a pulmonary embolism (PE)Scroll down for the correct answer!
The correct answer to today’s NCLEX-RN® Question is…
D. Development of a pulmonary embolism (PE)
Rationale: A PE occurs when a blood clot travels, or embolizes, through the vascular system and becomes lodged in a pulmonary vessel. This can cause life-threatening complications, such as hypoxia and respiratory failure. Patients with a DVT are at high risk for developing a PE, and the nurse should closely monitor for signs and symptoms of PE (e.g. shortness of breath, tachycardia, anxiety) and intervene as necessary.
Major Takeaway
The nurse should use clinical judgment to prioritize hypotheses related to deep vein thrombosis (DVT) by identifying actual and potential problems the patient may face. Patients with DVT are at risk for inadequate tissue perfusion, which can lead to formation of venous ulcers. They are also at risk for falls and pain, due to swelling and pain on the affected side. However, the most important complication is the increased risk for pulmonary embolism (PE), which can be life-threatening. The nurse should prioritize potential airway and breathing problems over circulatory problems and other issues (e.g., skin and pain).
Incorrect answer explanations
A. Unsteady gait with ambulation
Rationale: Patients with a DVT of the lower extremity may have an altered gait due to pain and swelling on the affected side. This is important because the patient can be at high risk for falls; however, it is not the priority complication.
B. Acute pain in the left lower leg
Rationale: Patients with a DVT may experience acute pain related to inflammation in the affected extremity. Although this is important, it is not the priority complication.
C. Formation of a venous stasis ulcer
Rationale: Patients with a DVT may develop a venous stasis ulcer due to build-up of fluid on the affected side. This pressure can lead to damage to the layers of the skin, eventually causing ulcer formation. This is important because it predisposes the patient to infection; however, it is not the priority complication.
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