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 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.

A. Recognize that the client nodding indicates an understanding of the information. B. Supplement spoken language with pictures. C. Speak to the client at an increased volume. D. Ask a family member of the client to interpret.

Correct Answer is B

Explanation

To effectively communicate with a client who speaks a different language, it is important to use alternative methods of communication. One effective method is to supplement spoken language with pictures or visual aids. This can help bridge the language barrier and enhance understanding between the nurse and the client.

Recognize that the client nodding indicates an understanding of the information: Nodding does not always indicate understanding. It could be a cultural gesture or a sign of politeness. Relying solely on nodding may lead to miscommunication and misunderstanding.

Speak to the client at an increased volume: Speaking louder does not necessarily overcome the language barrier. It may make communication more difficult and could be perceived as rude or intimidating.

Ask a family member of the client to interpret: While involving a family member may seem helpful, it is not always reliable or appropriate. Family members may not be proficient in both languages or may not fully understand medical terminology. Additionally, the client may desire privacy or may not want to burden their family members with the responsibility of interpretation.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

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?