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.

Answer and Explanation

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.

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Correct Answer is E,C,A,D,B

Explanation

Choice Erationale

Cleaning the puncture site with an antiseptic removes surface bacteria and contaminants to prevent infection. It also ensures that the blood sample is free from external substances that could interfere with test results.

Choice Crationale

Allowing the antiseptic to dry completely is crucial for proper skin preparation. Wet antiseptic can dilute the blood sample or cause irritation, and drying ensures optimal puncture and sample integrity.

Choice Arationale

Quickly piercing the site minimizes tissue damage and reduces discomfort. A swift puncture ensures an adequate capillary blood flow without excess trauma to the site.

Choice Drationale

Gently squeezing the site avoids excessive hemolysis, which can alter the blood glucose test results. Excessive pressure could force interstitial fluid into the sample, diluting it.

Choice Brationale

Applying blood to the test strip immediately after collection minimizes sample degradation. The test strip reacts to glucose levels, so prompt application ensures accurate readings.

A. Echinacea. B. Ginkgo biloba. C. Probiotics. D. Flaxseed powder.

Correct Answer is B

Explanation

Choice A rationale

Echinacea enhances immune function but has minimal effects on coagulation. It is not commonly associated with adverse interactions with anticoagulants like enoxaparin unless paired with other supplements causing significant immune changes.

Choice B rationale

Ginkgo biloba poses an increased bleeding risk due to antiplatelet effects, which can compound the anticoagulant properties of enoxaparin. This interaction necessitates close monitoring and communication with the provider.

Choice C rationale

Probiotics aid gastrointestinal health without influencing coagulation pathways or interacting significantly with anticoagulants. They are generally safe to continue unless contraindicated by other clinical factors.

Choice D rationale

Flaxseed powder contains omega-3 fatty acids, which may have mild anticoagulant properties. However, this interaction is usually not clinically significant unless used in large quantities alongside other anticoagulants. .

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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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Explanation

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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?