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. Placing a cap holder on the used needle before disposal does not prevent needlestick injuries and may increase the risk of accidental puncture.
B. Recapping the needle for disposal later increases the risk of needlestick injuries. It is recommended to avoid recapping needles whenever possible.
C. The immediate disposal of the used needle in a sharps container reduces the risk of needlestick injuries by eliminating the need for handling the needle after use.
D. Detaching the used needle and disposing of it promptly is appropriate, but it should be done directly into a sharps container to minimize the risk of needlestick injuries.

A. Massage areas around the edge of the client's cast with lotion. B. Avoid elevating the extremity when the client is resting in bed. C. Give the client a dull object to scratch the skin under the cast. D. Tell the client to report any numbness in their toes.

Correct Answer is D

Explanation

A. Massaging areas around the edge of the cast with lotion can introduce moisture and compromise the integrity of the cast, increasing the risk of skin breakdown and infection.
B. Elevating the extremity when the client is resting in bed helps reduce swelling and improve circulation, promoting healing. It is an appropriate action for a client with a cast.
C. Inserting objects under the cast can damage the skin, increase the risk of infection, or disrupt the integrity of the cast.

D. Numbness can indicate impaired circulation or nerve compression and warrants immediate assessment, making this the correct action.

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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

Naxlex Comprehensive Predictor Exams

A nurse administered an IM injection to a client. Which of the following actions should the nurse take to reduce the risk of a needlestick injury?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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