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 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.

A. Contact the provider to prescribe more pain medication for the client. B. Teach the client relaxation techniques for treatment of acute pain. C. Document the client's reaction to the administration of medication. D. Reevaluate the client's response to the medication in 30 min.

Correct Answer is D

Explanation

A. Contacting the provider to prescribe more pain medication may be necessary if the client's pain is not adequately controlled; however, reevaluation of the client's response to the initial dose should be done first.
B. Teaching relaxation techniques for acute pain management may be helpful, but it is not the priority at this moment when the client's pain is not adequately controlled.
C. Documenting the client's reaction to the medication is important but should not delay immediate action to address the client's unrelieved pain.
D. Reevaluating the client's response to the medication is the priority to determine if additional interventions are needed to manage the client's pain effectively.

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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 is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is postoperative and received hydromorphone 4 mg PO 15 min ago. The client tells the nurse, "My pain level is still 8 on a 0 to 10 scale." Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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