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?
Numbness of the affected extremity.
Muscle spasms.
Warmth of the affected extremity.
Absent pedal pulse.
The Correct Answer is C
Choice A rationale
Numbness of the affected extremity is not a classic symptom of deep-vein thrombosis (DVT). DVT primarily affects venous circulation, causing symptoms like pain, swelling, and warmth, rather than sensory deficits like numbness, which are more indicative of nerve involvement or arterial issues.
Choice B rationale
Muscle spasms are not a hallmark sign of DVT. They are typically associated with muscular or neuromuscular issues. DVT symptoms are more focused on vascular changes such as pain, swelling, and increased warmth in the affected area due to impaired venous return.
Choice C rationale
Warmth of the affected extremity occurs due to localized inflammation caused by clot formation in the vein. The body’s inflammatory response to the thrombus leads to vasodilation and increased blood flow to the area, resulting in the sensation of warmth upon palpation.
Choice D rationale
An absent pedal pulse is not indicative of DVT, as this condition involves venous, not arterial, circulation. A missing pulse suggests arterial occlusion or peripheral vascular disease, distinct from venous thromboembolism like DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Pain patches containing medications like fentanyl are designed for continuous absorption over 72 hours and should not be removed at bedtime. Removing the patch prematurely could lead to a sudden drop in medication levels, compromising pain control. The pharmacokinetics of transdermal patches ensure a steady release of analgesic agents without requiring frequent application.
Choice B rationale
Around-the-clock analgesia provides consistent plasma drug levels, ensuring better pain control compared to as-needed dosing. By preventing peaks and troughs in medication levels, this approach enhances efficacy and improves the client’s quality of life. Studies confirm this approach reduces breakthrough pain in terminal cancer patients.
Choice C rationale
Intramuscular injections are not the preferred route for long-term pain management due to their variable absorption, potential for tissue damage, and patient discomfort. Oral, transdermal, or intravenous routes are safer, more effective options for sustained analgesia.
Choice D rationale
Tolerance, a normal physiological response, does not necessitate dose reduction but rather dose adjustment to maintain therapeutic effects. Reducing the dose can result in inadequate pain relief and increased patient suffering. Evidence supports dose titration based on pain severity and patient needs.
Correct Answer is A
Explanation
Choice A rationale
Tingling indicates hypocalcemia due to parathyroid gland injury, a complication of thyroidectomy. Hypocalcemia arises when parathyroid hormone secretion decreases, impairing calcium homeostasis. Normal serum calcium ranges are 8.5–10.2 mg/dL.
Choice B rationale
Serosanguineous drainage is normal wound exudate consisting of serum and red blood cells. It reflects standard postoperative healing, provided there is no excessive volume or purulent drainage suggesting infection.
Choice C rationale
Sore throat is expected due to endotracheal intubation during anesthesia. Transient inflammation resolves spontaneously without clinical intervention.
Choice D rationale
Incisional soreness is typical and does not suggest complications. It results from tissue disruption during surgery and should subside as healing progresses.
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