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 C

Explanation

Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (PaCO2) by the lungs, leading to an increase in the partial pressure of carbon dioxide (hypercapnia) and a decrease in pH.

In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), indicating respiratory acidosis. The pH is below the normal range, suggesting acidemia.

The other ABG values (PaO2, oxygen saturation, and bicarbonate) are within or close to normal limits, which do not support the diagnosis of metabolic acidosis, respiratory alkalosis, or metabolic alkalosis.

A. A client's response to interventions implemented. B. The frequency in which a blood pressure is taken. C. Interventions implemented in response to a client's blood pressure. D. The site where the blood pressure was obtained. E. A client's position when the blood pressure was obtained.

Correct Answer is ["A","B","C","D","E"]

Explanation

A) A client's response to interventions implemented: It's essential to document how the client responds to interventions implemented in response to their blood pressure. This provides valuable information on the effectiveness of the interventions and helps in assessing the client's condition.

B) The frequency in which a blood pressure is taken: Documenting the frequency of blood pressure measurements is crucial for tracking trends and changes over time. It ensures a comprehensive assessment of the client's cardiovascular status.

C) Interventions implemented in response to a client's blood pressure: Documenting the interventions implemented in response to a client's blood pressure helps in maintaining an accurate record of the care provided and ensures continuity of care among healthcare providers.

D) The site where the blood pressure was obtained: Documenting the site where the blood pressure was obtained is important for standardizing the measurement process and ensuring consistency. Common sites include the brachial artery, but documenting the specific site provides clarity and accuracy.

E) A client's position when the blood pressure was obtained: Documenting the client's position during blood pressure measurement is essential because blood pressure can vary based on body position. It ensures that accurate comparisons can be made between readings and provides valuable information for clinical decision-making.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information? (Select All that Apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

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