A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has

deep-vein thrombosis. Which of the following findings should the nurse expect in the aﬀected extremity?

Absent dorsal pedal pulse

Shiny, hairless skin

Irregular, bulging veins

Dull, aching pain

Answer and Explanation

The Correct Answer is D

Choice A:

An absent dorsal pedal pulse would indicate a vascular problem such as arterial occlusion, not a deep vein thrombosis (DVT). In the case of DVT, blood flow in the veins is obstructed, but the arterial pulse, which is related to arterial circulation, should remain intact unless there is a separate arterial issue. Therefore, absent pulses are not characteristic of DVT.

Choice B:

Shiny, hairless skin is a sign typically associated with chronic arterial insufficiency, not DVT. This skin change occurs when there is poor arterial blood flow, which leads to a lack of nourishment for the skin, causing it to become thin and shiny. In contrast, DVT affects the veins and does not usually cause these skin changes in the acute phase.

Choice C:

Irregular, bulging veins are indicative of varicose veins or chronic venous insufficiency, not a DVT. Varicose veins occur when the veins become swollen and twisted due to weak or damaged valves. DVT, on the other hand, involves the formation of a clot in the deep veins and does not typically cause the veins to bulge visibly, especially in the early stages.

Choice D:

Dull, aching pain is a common symptom associated with deep vein thrombosis. This pain typically occurs in the affected extremity and is often described as a constant, aching sensation. The pain can worsen with movement or standing and is due to the inflammation and obstruction caused by the blood clot in the deep veins. This is a hallmark sign of DVT, along with swelling and redness in the affected limb.

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Correct Answer is B

Explanation

The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood ﬂow to the limb.

The other options are also concerning and should be reported to the healthcare provider.

a) A cooler footmay indicate decreased blood ﬂow to the limb.

c) A capillary refill time of 5 secondsmay also indicate decreased blood ﬂow.

d) A pain level of 8 on a scale from 0 to 10should also be reported and addressed.

A. Many people have colostomies, and they live full lives B. "Would it help to speak to someone else who has a colostomy? C. Why don't you want people to see the colostomy bag? D. The colostomy is probably only temporary

Correct Answer is A

Explanation

a. "Many people have colostomies and they live full lives."

Explanation:

The correct answer is a. "Many people have colostomies and they live full lives."

When a client expresses concerns or distress regarding their colostomy and not wanting others to see the colostomy bag, it is essential for the nurse to provide support and reassurance. Responding by acknowledging that many people live full lives with colostomies helps normalize the experience and oﬀers hope to the client.

Option b, "Would it help to speak to someone else who has a colostomy?" may be a helpful suggestion, but it should not be the initial response. First, it is important to provide immediate reassurance and support to the client before exploring additional resources or contacts.

Option c, "Why don't you want people to see the colostomy bag?" may be seen as invasive and may put the client on the spot, potentially making them feel uncomfortable or defensive. It is important to create a safe and non-judgmental environment for the client.

Option d, "The colostomy is probably only temporary," assumes information about the client's specific situation that may not be accurate. It is important to avoid making assumptions about the duration or permanence of the colostomy unless the client has shared that information. Providing false reassurances can negatively impact the client's trust and emotional well-being.

By responding with the statement that many people live full lives with colostomies, the nurse oﬀers support, normalizes the client's experience, and promotes a positive outlook for the client's future.

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A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has deep-vein thrombosis. Which of the following findings should the nurse expect in the aﬀected extremity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

Correct Answer is B

Explanation

A nurse is caring for a client who has a new colostomy. The client tells the nurse, "I don't want anyone to see me with this bag." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has

deep-vein thrombosis. Which of the following findings should the nurse expect in the aﬀected extremity?