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 B

Explanation

A. Disposing of used syringes in the household trash poses a risk of accidental needle sticks to others. The correct method of disposal is using a puncture-resistant container.
B. Storing the current bottle of insulin in the refrigerator is the correct practice to maintain the stability and effectiveness of the insulin. Insulin should be kept refrigerated until opened and
then can be kept at room temperature for up to 28 days.

C. Holding the needle at a 15° angle to the skin is not the recommended technique for insulin injection. The correct angle for subcutaneous insulin injection is usually 45 or 90 degrees, depending on the client's body habitus and the length of the needle.
D. Using an injection site that is 1 inch from the previous site may lead to lipohypertrophy, a condition characterized by fatty tissue buildup under the skin, which can affect insulin absorption. It is recommended to rotate injection sites to avoid this complication.

A. The adolescent brother criticizes the parents' plan to have a funeral service. B. The school-age sister views death as being a type of temporary sleep. C. The adolescent brother fears the terminal illness is contagious. D. The school-age sister is concerned about the impact of her sibling's death on herself

Correct Answer is D

Explanation

A. The adolescent brother criticizing the parents' plan for a funeral service might indicate a coping mechanism or emotional response but is not a typical response.
B. The school-age sister viewing death as a type of temporary sleep demonstrates a common misconception about death in children but is not necessarily the most likely response from siblings.
C. The adolescent brother fearing the terminal illness is contagious might occur due to a lack of understanding or misinformation but is not a common response among siblings.
D. The school-age sister being concerned about the impact of her sibling's death on herself is a common response. Siblings often have concerns about their own feelings and the changes that will occur within the family dynamic after the loss of a sibling.

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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 who was diagnosed with diabetes mellitus and requires insulin injections. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's siblings should the nurse expect?

Correct Answer is D

Explanation

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