A nurse is caring for a client who is postoperative. For which of the following findings should the nurse suspect the client is experiencing a deep- vein thrombosis?

Muscle spasms

Absent pedal pulse

Numbness of the affected extremity

Warmth of the affected extremity

Answer and Explanation

The Correct Answer is D

A. Muscle spasms: These are not typically associated with DVT.
B. Absent pedal pulse: This suggests arterial occlusion, not venous thrombosis.
C. Numbness of the affected extremity: Numbness is not a classic sign of DVT and might indicate a nerve-related issue.
D. Warmth of the affected extremity. Warmth is a hallmark sign of DVT due to localized inflammation and impaired venous circulation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Empty the pouch when it is 1/3 to 1/2 full: This prevents the weight of the pouch from causing leaks or pulling on the stoma.
B. Use a standard enema set to irrigate the colostomy: This is incorrect as a standard enema set is not typically used. Colostomy irrigation requires specific equipment and is not performed routinely.
C. Cleanse the skin surrounding the stoma with moisturizing soap: Moisturizing soap can leave a residue that interferes with adhesive barriers. Mild, non-moisturizing soap or just water should be used.
D. Cut the opening in the skin barrier 1/4 inch larger than the stoma: The opening should fit closely to the stoma to protect the surrounding skin from irritation and leakage.

A. Encourage three large meals daily. B. Season foods with spices. C. Provide a high-calorie diet. D. Administer an antiemetic after each meal.

Correct Answer is C

Explanation

A. "Encourage three large meals daily.": Smaller, more frequent meals are often better tolerated, especially if the client has nausea or anorexia.
B. "Season foods with spices.": Spices might irritate the gastrointestinal tract, particularly if mucosal lesions are present.
C. "Provide a high-calorie diet.": Clients with AIDS often have increased energy needs due to hypermetabolism and malnutrition; a high-calorie diet helps maintain weight and energy levels.
D. "Administer an antiemetic after each meal.": Antiemetics should be administered before meals to prevent nausea and improve food intake.

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A nurse is caring for a client who is postoperative. For which of the following findings should the nurse suspect the client is experiencing a deep- vein thrombosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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