A nurse is caring for a client who is postoperative following vascular surgery.
Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?
Dull, aching calf pain.
Positive Kernig's sign.
Soft, pliable calf muscle.
Positive Homan's sign.
None
None
The Correct Answer is A
The correct answer is Choice A: Dull, aching calf pain.
Choice A rationale:
Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT), which can occur postoperatively, especially after vascular surgery. This pain is often due to a blood clot forming in the deep veins of the leg.
Choice B rationale:
Positive Kernig's sign is associated with meningitis and not typically related to thrombus formation.
Choice C rationale:
Soft, pliable calf muscle is not indicative of a thrombus. A thrombus would more likely cause tenderness and swelling.
Choice D rationale:
Positive Homan's sign (pain in the calf upon dorsiflexion of the foot) can be an indicator of DVT, but it is less reliable than dull, aching calf pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Elevating the head of the bed to a 45-degree angle is important for clients with obstructive sleep apnea (OSA) to help prevent airway obstruction during sleep. However, this should not be the nurse's immediate priority before leaving the client. Ensuring the client's positive airway pressure (PAP) device is properly applied is more crucial.
Choice C rationale:
While locking the side rails in place is generally essential for safety, it is not the most critical intervention for a client with OSA and urination issues. Ensuring proper use of the PAP device is a higher priority.
Choice D rationale:
Removing dentures or other oral appliances is important for preventing airway obstruction in clients with OSA, but it should not take precedence over ensuring the use of the PAP device. The nurse should address the immediate respiratory needs of the client.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale:
Gastrointestinal bloating is not a typical clinical manifestation of left-sided heart failure. Left-sided heart failure primarily affects the pulmonary circulation, leading to symptoms such as dyspnea and orthopnea, but not gastrointestinal symptoms.
Choice B rationale:
Jugular vein distention is more commonly associated with right-sided heart failure. In left-sided heart failure, the congestion typically occurs in the pulmonary circulation, leading to respiratory symptoms, whereas jugular vein distention is a sign of elevated central venous pressure often seen in right-sided heart failure.
Choice C rationale:
Tachycardia is a common clinical manifestation of left-sided heart failure. As the heart struggles to pump blood effectively, it compensates by increasing the heart rate to maintain cardiac output.
Choice D rationale:
Orthopnea is a classic symptom of left-sided heart failure. Clients with left-sided heart failure often experience difficulty breathing when lying flat and find relief when sitting upright. This is due to the redistribution of blood in the lungs when changing positions.
Choice E rationale:
Dyspnea is another hallmark symptom of left-sided heart failure. It is caused by the accumulation of fluid in the lungs (pulmonary edema) due to the impaired ability of the left ventricle to effectively pump blood, leading to congestion in the pulmonary circulation.
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