A client presents with swelling, redness, and warmth in one leg. The nurse suspects deep vein thrombosis (DVT). What initial assessment should the nurse perform to confirm the presence of DVT?
Auscultating the lungs for crackles.
Checking for a positive Homans' sign.
Measuring blood pressure in both arms.
Performing a capillary refill test.
The Correct Answer is B
A) This choice is incorrect because auscultating the lungs for crackles is not directly related to confirming the presence of deep vein thrombosis (DVT). Lung auscultation may be performed to assess for potential complications of DVT, such as pulmonary embolism.
B) This choice is correct. Homans' sign is a clinical test used to assess for the presence of DVT. The nurse flexes the client's knee and gently dorsiflexes the foot. A positive Homans' sign is indicated by calf pain or discomfort during dorsiflexion and may suggest the presence of a blood clot in the deep veins of the leg.
C) This choice is incorrect because measuring blood pressure in both arms is not a specific assessment for deep vein thrombosis (DVT). It may be done as part of a routine assessment but does not confirm the presence of DVT.
D) This choice is incorrect because performing a capillary refill test is not specific to DVT assessment. Capillary refill is a measure of peripheral perfusion and may be useful in assessing overall circulatory status, but it does not directly confirm the presence of DVT.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) This choice is incorrect because venous Doppler ultrasound is a non-invasive imaging test commonly used to diagnose DVT. However, it is not considered the gold standard due to potential limitations in visualizing small clots and deep veins.
B) This choice is incorrect because the D-dimer blood test is a screening test used to detect the presence of blood clot breakdown products. While it can help rule out DVT when negative, it is not the definitive diagnostic test.
C) This choice is incorrect because magnetic resonance imaging (MRI) is a sensitive imaging modality but is not considered the gold standard for diagnosing DVT. MRI may be used in specific cases, but contrast venography remains the gold standard.
D) This choice is correct. Contrast venography involves injecting contrast dye into the veins and taking X-ray images to visualize the blood flow and detect any clots. It is considered the gold standard for diagnosing DVT, as it provides direct visualization of the clot and the extent of its involvement.
Correct Answer is B
Explanation
A) This choice is incorrect because palpating the pulses in the extremities primarily assesses arterial blood flow, not venous thrombosis. While pulse assessment is essential, it is not the priority for identifying DVT-related manifestations.
B) This choice is correct. Measuring calf and thigh circumference can help identify possible DVT by comparing the affected leg's size to the unaffected one. DVT can cause localized swelling in the affected limb.
C) This choice is incorrect because auscultating the lungs for crackles is not a specific assessment for DVT. Crackles may be present in pulmonary edema, which can be a complication of DVT, but they do not directly assess the presence of a blood clot in the veins.
D) This choice is incorrect because performing a capillary refill test is primarily used to assess peripheral perfusion and is not specific to DVT assessment.
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