The nursing care plan for a client in traction includes regular assessments for venous thromboembolism. When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

Increased circulation of the calf

Pale-appearing calf

Increased warmth in the calf

Loss of sensation to the calf

Swelling and tenderness of the calf

Answer and Explanation

The Correct Answer is E

Choice A reason: Increased circulation of the calf is not a sign or symptom of DVT, but a normal finding of the blood flow in the leg. It can be assessed by palpating the pulses, checking the capillary refill, or observing the skin color and temperature.

Choice B reason: Pale-appearing calf is not a sign or symptom of DVT, but a sign of arterial insufficiency or ischemia. It indicates the reduced blood supply and oxygen delivery to the tissues, which can cause pain, numbness, or coldness of the leg.

Choice C reason: Increased warmth in the calf is not a specific sign or symptom of DVT, but a possible sign of inflammation or infection. It may be accompanied by redness, swelling, or fever, which can indicate a local or systemic inflammatory response.

Choice D reason: Loss of sensation to the calf is not a sign or symptom of DVT, but a sign of nerve damage or compression. It may be caused by trauma, injury, diabetes, or other conditions that affect the peripheral nervous system.

Choice E reason: Swelling and tenderness of the calf is a common sign or symptom of DVT, as it indicates the presence of a blood clot in the deep veins of the leg. It may also cause pain, cramping, or heaviness of the leg, which can worsen with movement or standing.

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Correct Answer is B

Explanation

Choice A reason: Institute of Medicine (IOM) research is not a method for developing procedures, but an organization that conducts health-related studies and provides recommendations for improving health care quality and safety.

Choice B reason: Evidence-based practice is the correct method for developing procedures. It is the process of integrating the best available research evidence with clinical expertise and patient preferences to make decisions about health care.

Choice C reason: Knowledge, skills, and attitude are not a method for developing procedures, but the components of competency that nurses need to provide safe and effective care.

Choice D reason: Core measures are not a method for developing procedures, but a set of standardized performance indicators that evaluate the quality of care for specific conditions or procedures.

A. Remove the drain B. Continue to assess and monitor intake and output every shift C. Elevate affected leg and place client in Trendelenburg position D. Notify the surgeon and make aware of this finding E. None of the above

Correct Answer is B

Explanation

Choice A reason: Removing the drain is not an appropriate action for the nurse to take, as it may cause bleeding, infection, or hematoma at the surgical site. The drain is placed to prevent the accumulation of fluid and blood in the hip joint, and it should be removed only by the surgeon when the drainage is minimal and the wound is healing.

Choice B reason: Continuing to assess and monitor intake and output every shift is an appropriate action for the nurse to take, as it helps to evaluate the fluid balance and the renal function of the client. The nurse should record the amount, color, and consistency of the drainage, and compare it with the previous measurements. The nurse should also monitor the vital signs, the hemoglobin and hematocrit levels, and the signs of dehydration or fluid overload.

Choice C reason: Elevating the affected leg and placing the client in Trendelenburg position is not an appropriate action for the nurse to take, as it may cause hip dislocation, hypotension, or respiratory distress. The nurse should keep the affected leg slightly abducted and aligned with the body, and avoid flexing the hip more than 90 degrees. The nurse should also maintain the client in a semi-Fowler's or supine position, and avoid turning the client to the affected side.

Choice D reason: Notifying the surgeon and making aware of this finding is not an appropriate action for the nurse to take, as it is not an urgent or abnormal situation. The nurse should report the drainage to the surgeon only if it exceeds the expected amount, which is usually less than 200 mL in the first 24 hours after surgery, or if it changes in color, consistency, or odor.

Choice E reason: None of the above is not a correct choice, as there is one option that matches the most appropriate action for the nurse to take.

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The nursing care plan for a client in traction includes regular assessments for venous thromboembolism. When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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