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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should administer scheduled pain medications to a client who is near death. This is an important nursing intervention to ensure that the client is comfortable and free from pain.
b) Providing oral care every 6 hours is important, but it may not be the highest priority for a client who is near death.
c) Administering liquids using a syringe may not be necessary or appropriate for a client who is near death.
d) Whispering when talking to family members is not necessary. The nurse should communicate openly and honestly with the family members.
Correct Answer is B
Explanation
The charge nurse should explain to the assistive personnel (AP) that one of the responsibilities of a licensed practical nurse (LPN) is providing direct client care. LPNs work under the supervision of registered nurses (RNs) and are trained to deliver basic nursing care to clients. This includes tasks such as administering medications, monitoring vital signs, dressing wounds, assisting with activities of daily living (ADLs), and reporting any changes in the client's condition to the RN.
The other options are not typically within the scope of practice for an LPN:
a. Coordinating client care: The coordination of client care is primarily the responsibility of the RN. While LPNs may contribute to the coordination of care by providing input and collaborating with the healthcare team, the overall coordination is usually managed by the RN.
c. Assessing a client's health status: Assessing a client's health status is a role primarily performed by RNs. LPNs may gather data and contribute to the assessment process, but the comprehensive assessment and interpretation of data is typically the responsibility of the RN.
d. Identifying specific client health problems: Identifying specific client health problems and formulating nursing diagnoses is part of the RN's role. LPNs may assist in collecting data and providing input, but the identification and formulation of nursing diagnoses are within the scope of practice of the RN.
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