A nurse is caring for a client who is postoperative following cardiac surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

Positive Kernig's sign

Dull, aching calf pain

Soft, pliable calf muscle

Positive Homan's sign

Answer and Explanation

Correct Answer : B,D

A. Positive Kernig's sign:

Positive Kernig's sign is associated with meningitis, not thrombosis. It is a clinical sign where pain is elicited when the hip is flexed at a 90-degree angle and then the knee is extended. This sign is not relevant for identifying a thrombus.

B. Dull, aching calf pain:

Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT). Pain, swelling, and tenderness in the calf are typical manifestations of a thrombus in the leg veins. This symptom should alert the nurse to the possibility of a thrombus.

C. Soft, pliable calf muscle:

A soft, pliable calf muscle is not indicative of a thrombus. In the case of DVT, the affected leg is usually swollen, firm, and tender. Thus, this manifestation does not suggest the presence of a thrombus.

D. Positive Homan's sign:

Positive Homan's sign is identified when there is pain in the calf upon dorsiflexion of the foot. This sign can be indicative of DVT. Although not highly specific or sensitive, it is one of the traditional signs used to assess for the presence of a thrombus in the leg.

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Correct Answer is D

Explanation

(A) Determine the client’s blood pressure 1 min after each position change: While it’s important to check the client’s blood pressure after each position change when assessing for orthostatic hypotension, this is not the first step. The nurse should first establish a baseline blood pressure reading with the client in a supine position.

(B) Place the client in a sitting position: Although the nurse will eventually need to check the client’s blood pressure in a sitting position, the first step is to get a baseline reading with the client in a supine position.

(C) Assist the client into a standing position: The nurse will eventually assist the client into a standing position to check for changes in blood pressure, but this is not the first step. The initial step is to get a baseline reading with the client in a supine position.

(D) Check the blood pressure with the client in a supine position: This is the most appropriate first step. When checking for orthostatic hypotension, the nurse should first check the client’s blood pressure while they are lying flat (supine). This provides a baseline reading against which subsequent readings (taken when the client is sitting and standing) can be compared. If there’s a significant drop in blood pressure upon standing, this could indicate orthostatic hypotension.

A. "I’ll breathe deeply and cough every 4 hours." B. "I’ll splint my incision with a pillow to cough." C. " I’ll start to use the incentive spirometer when I can get out of bed." D. " I’ll lie flat in bed to cough and deep breath."

Correct Answer is B

Explanation

(A) "I’ll breathe deeply and cough every 4 hours."
Deep breathing and coughing exercises should be done more frequently, typically every 1-2 hours while awake, to help prevent respiratory complications such as atelectasis and pneumonia.

(B) "I’ll splint my incision with a pillow to cough."
This statement indicates an understanding of the instructions. Splinting the incision with a pillow helps support the surgical site, reduces pain, and makes coughing more effective and less uncomfortable. This technique is important for clients to use to help clear secretions from the lungs postoperatively.

(C) "I’ll start to use the incentive spirometer when I can get out of bed."
The use of an incentive spirometer should begin as soon as possible, usually while the client is still in bed, to encourage deep breathing and prevent postoperative respiratory complications. It should not be delayed until the client can get out of bed.

(D) "I’ll lie flat in bed to cough and deep breathe."
Lying flat is not the optimal position for deep breathing and coughing exercises, as it can make it more difficult to fully expand the lungs. The client should be positioned with the head of the bed elevated or sitting up to facilitate better lung expansion and more effective coughing.

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A nurse is caring for a client who is postoperative following cardiac surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

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