The nurse is evaluating the expected outcomes following thrombolytic therapy for a right leg deep vein thrombosis. Which finding(s) confirms a positive outcome? Select all that apply.

Right extremity comparable in size to left

No bleeding or bruising noted

Right extremity pink

Client denies pain

Pedal pulse thready

Answer and Explanation

Correct Answer : A,C,D

A. Right extremity comparable in size to left: Reduction in swelling indicates improved venous return and resolution of the thrombus. Symmetry between extremities suggests successful clot dissolution and reduced obstruction in the affected vein.
B. No bleeding or bruising noted: While this is a desirable side effect outcome, it is not a direct measure of thrombolytic effectiveness. Thrombolytics carry bleeding risk, but the absence of bruising doesn’t confirm clot resolution.
C. Right extremity pink: A pink, well-perfused extremity suggests adequate blood flow, which reflects successful reperfusion. This indicates improved circulation after clot breakdown and is a positive therapeutic result.
D. Client denies pain: Pain is a hallmark symptom of DVT due to inflammation and obstruction. Decreased or absent pain after thrombolytic therapy reflects clinical improvement and reduced clot burden.
E. Pedal pulse thready: A thready pulse may indicate decreased perfusion and is not a reassuring finding. Effective thrombolytic therapy should lead to strong, palpable pulses if circulation has improved.

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Correct Answer is D

Explanation

A. The spleen is lymphoid tissue in the upper chest that contains stem cells: The spleen is located in the left upper abdomen, not the chest, and it does not house hematopoietic stem cells. While it is lymphoid tissue, it does not primarily contain stem cells; stem cells are mainly found in the bone marrow.
B. The spleen assists with blood clotting: While the spleen stores platelets, its primary function is not clotting. It plays a secondary role in hemostasis but is more essential for filtering blood and immune responses.
C. The spleen is a large lymph node and takes waste debris away: The spleen is not a lymph node, although both are part of the lymphatic system. Lymph nodes filter lymph fluid, while the spleen filters blood. While the spleen does remove waste debris (through phagocytosis), it's not accurate to describe it as a large lymph node.
D. The spleen is a lymphatic structure and assists with phagocytosis: The spleen plays a critical role in immune defense by filtering blood, removing pathogens, and facilitating phagocytosis of old or damaged cells. Preserving it reduces the risk of overwhelming infections.

A. A grilled chicken sandwich with mayonnaise B. A hot dog with ketchup C. A natural fruit salad with nuts D. A fresh grilled tuna entrée with fresh asparagus

Correct Answer is B

Explanation

A. A grilled chicken sandwich with mayonnaise: While some sodium is present in bread and condiments, grilled chicken and mayonnaise generally contain moderate sodium levels. With portion control and low-sodium ingredients, this can fit into a restricted sodium diet.
B. A hot dog with ketchup: Hot dogs are highly processed and contain high amounts of sodium and preservatives. Ketchup adds even more sodium, making this combination unsuitable for clients on a low sodium diet.
C. A natural fruit salad with nuts: Fresh fruits are naturally low in sodium, and unsalted nuts can be included as well. This option is both heart-healthy and supportive of a low sodium dietary plan.
D. A fresh grilled tuna entrée with fresh asparagus: When prepared without canned or pre-seasoned components, fresh tuna and vegetables are low in sodium. This meal provides lean protein and nutrients without excess salt.

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The nurse is evaluating the expected outcomes following thrombolytic therapy for a right leg deep vein thrombosis. Which finding(s) confirms a positive outcome? Select all that apply.

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Explanation

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