A nurse is collecting data from a patient who is postoperative following abdominal surgery. Which of the following findings should the nurse suspect deep vein thrombosis (DVT)?
Decreased pedal pulses
Unilateral leg edema
Ecchymosis on the foot and ankle
Coolness of the skin
The Correct Answer is B
Choice A reason: Decreased pedal pulses could indicate a vascular issue but are not specific to DVT.
Choice B reason: Unilateral leg edema, especially when it is sudden, can be a sign of DVT and is the most indicative of the choices provided.
Choice C reason: Ecchymosis, or bruising, on the foot and ankle can be caused by many factors and is not specific to DVT.
Choice D reason: Coolness of the skin can be a sign of poor circulation but is not specific to DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Elevating the patient in a high Fowler's position can help improve lung expansion and oxygenation, and using an incentive spirometer along with coughing can help prevent atelectasis and pneumonia, which are common postoperative complications.
Choice B reason: Increasing oxygen to 70% without a specific indication could lead to oxygen toxicity, especially without assessing the patient's current oxygenation status.
Choice C reason: Switching to a rebreather mask is not indicated based on the given ABG results and could lead to CO2 retention.
Choice D reason: Positioning the patient prone and performing postural drainage are not typically first-line interventions for a patient one day post-thoracotomy and could be contraindicated due to the recent surgery.
Correct Answer is B
Explanation
Choice A reason: While bed rest may be required immediately after surgery, patients are typically encouraged to mobilize as soon as possible to prevent complications.
Choice B reason: Using a special soap the evening before surgery is a common preoperative instruction to reduce the risk of infection.
Choice C reason: A CPM machine is often used after hip replacement surgery to promote movement and prevent joint stiffness.
Choice D reason: A heating pad is generally not recommended on the operative site immediately after surgery due to the risk of burns and bleeding.
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The correct answer is choice B. “You will use a special soap to shower with the evening before your surgery.” Choice A rationale: Remaining in bed for at least the first 24 hours is not typically recommended. Early mobilization is encouraged to prevent complications such as blood clots and to promote faster recovery. Choice B rationale: Using a special soap to shower with the evening before surgery is a common preoperative instruction. This helps reduce the risk of infection by decreasing the number of bacteria on the skin. Choice C rationale: Continuous passive motion (CPM) machines are generally used for knee replacement surgeries, not hip replacements. They help in maintaining joint mobility and preventing stiffness, but are not standard for hip surgeries. Choice D rationale: Using a heating pad on the operative site is not recommended as it can increase swelling and the risk of burns. Cold therapy is usually preferred to reduce pain and inflammation postoperatively. |
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