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 A
Explanation
The correct answer is choiceA. Heart rate 50/min.
Choice A rationale:
Atenolol is a beta-blocker that can significantly lower heart rate.A heart rate of 50/min is considered bradycardia (slow heart rate), and administering atenolol could further decrease the heart rate to a dangerously low level. Therefore, the nurse should withhold the medication in this case.
Choice B rationale:
A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not contraindicate the use of atenolol. Therefore, this finding would not require withholding the medication.
Choice C rationale:
An oxygen saturation of 95% is within the normal range (typically 95-100%) and does not contraindicate the use of atenolol. Thus, this finding would not necessitate withholding the medication.
Choice D rationale:
While a blood pressure of 160/94 mm Hg indicates hypertension, atenolol is often prescribed to manage high blood pressure. Therefore, this finding would not require withholding the medication.
Correct Answer is C
Explanation
Choice A rationale: Tuberculosis treatment with rifampin typically lasts 6 to 9 months. Lifelong therapy is not required for TB, and unnecessary prolonged use increases the risk of drug resistance and hepatotoxicity.
Choice B rationale: Rifampin induces liver enzymes that accelerate the metabolism of oral contraceptives, making them less effective. It does not cause amenorrhea, but it necessitates the use of non-hormonal backup contraception.
Choice C rationale: Rifampin causes a harmless reddish-orange discoloration of urine, sweat, tears, and saliva. This can permanently stain soft contact lenses, so clients are advised to wear eyeglasses during the treatment course.
Choice D rationale: A yellow tint to the skin or sclera indicates jaundice, which is a sign of hepatotoxicity. This is a serious adverse effect rather than an expected reaction and must be reported immediately.
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