A nurse is collecting data from a client who is 24 hr postoperative following a total knee arthroplasty. Which of the following findings on the operative leg should the nurse identify as a manifestation of a deep-vein thrombosis?
Increase in calf size
Capillary refill of 2 seconds
Palpable cord-like vein
Extremity feels cool to the touch
The Correct Answer is C
A. An increase in calf size can be a sign of deep-vein thrombosis (DVT), but it is not specific to
DVT and can occur with other conditions such as edema.
B. Capillary refill of 2 seconds is within the expected range and is not indicative of DVT.
C. A palpable cord-like vein is a classic sign of DVT and should be further assessed and reported for appropriate intervention.
D. An extremity feeling cool to the touch can be a sign of impaired circulation but is not specific to DVT and can occur with other vascular conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Maintaining the elbow flexed at a 90-degree angle is a general instruction for cane use but may not be applicable to all clients. It depends on individual comfort and the type of cane being used.
B. Correct. Placing the cane on the stronger side of the body helps to provide stability and support during ambulation, especially for clients with rheumatoid arthritis.
C. Incorrect. Placing the cane forward 5 to 10 cm (2 to 4 in) helps ensure proper positioning and support but is not specifically related to the side of placement.
D. Incorrect. Moving the stronger leg forward first is a general instruction for cane use but may not be specific to all clients or situations
Correct Answer is A
Explanation
A. Using an adhesive remover can help gently remove the colostomy appliance without causing skin irritation or damage. It can aid in maintaining skin integrity around the stoma.
B. Scrubbing the skin around the colostomy can cause skin trauma and increase the risk of infection. Gentle cleansing with warm water and mild soap is recommended.
C. There is typically no need to suction stool from a colostomy bag. Stool drainage occurs naturally into the bag, and suctioning is not a routine part of colostomy care.
D. Colostomy bags should be emptied when they are about one-third to one-half full to prevent
leakage and ensure comfort for the client. Waiting until the bag is three-fourths full may increase the risk of accidental leakage.
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