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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Cleansing the perineal area from back to front can introduce bacteria from the rectum to the urinary tract, increasing the risk of infection. Front to back is the recommended direction for cleansing.
B. Washing the perineal area with povidone-iodine twice daily may be too frequent and could potentially irritate the area. Gentle cleansing with warm water is typically recommended.
C. Changing the perineal pad with each void helps to maintain cleanliness and prevent infection by reducing the buildup of moisture and bacteria.
D. Wiping the perineal area with a soft towel is appropriate for gentle cleansing but does not address the importance of changing the perineal pad regularly.

A. Complete an incident report. B. Allow the current solution to finish infusing, then change the bag. C. Document that an error occurred in the client's medical record D. Stop the infusion

Correct Answer is D

Explanation

- A: Completing an incident report is an important step after addressing any immediate risks to the patient. It is a part of the process to document errors and prevent future occurrences, but it does not take precedence over the patient's immediate safety.
- B: Allowing the current solution to finish could harm the patient, depending on the contents of the IV solution and the patient's condition. Immediate action is required to prevent potential adverse effects.
- C: Documentation in the medical record is crucial, but it should be done after the error has been corrected and the patient's safety is ensured. The immediate priority is to address the error.
- D: Stopping the infusion is the most immediate and appropriate action to prevent further harm to the patient. Once the infusion is stopped, the nurse can then take further steps to correct the error and follow up with the necessary documentation and reports.

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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?

Nursing Test Bank

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Correct Answer is D

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