A nurse is caring for a client who has deep vein thrombosis (DVT) of their right lower leg. Which of the following manifestations should the nurse expect? (Select All that Apply.)
Warmth
Erythema
Swelling
Numbness
Bleeding
Correct Answer : A,B,C
A. Warmth: Warmth over the affected area is a typical sign of DVT. It results from localized inflammation and increased blood flow due to the clot obstructing venous return and irritating the vessel wall.
B. Erythema: Erythema, or redness, often occurs in the area where the thrombus is located. It reflects the inflammatory response triggered by the presence of the clot in the vein.
C. Swelling: Swelling in the affected limb is one of the most common signs of DVT. It results from impaired venous return and fluid buildup due to the obstruction caused by the clot.
D. Numbness: Numbness is not typically associated with DVT. While swelling can sometimes compress nearby nerves and cause discomfort, numbness is not a hallmark feature and would warrant evaluation for other potential causes.
E. Bleeding: Bleeding is not a manifestation of DVT itself. DVT involves clot formation within a vein, not bleeding. However, anticoagulant therapy used to treat DVT can increase the risk of bleeding, but that is a side effect of treatment, not a sign of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. 3% sodium chloride: A serum sodium level of 115 mEq/L is dangerously low, indicating severe hyponatremia. The nurse should anticipate that a hypertonic saline solution such as 3% sodium chloride will be prescribed to rapidly increase the sodium concentration in the blood and treat the underlying SIADH.
B. Dextrose 5% in 0.99% sodium chloride: This is an isotonic solution and would not be suitable for treating severe hyponatremia in SIADH, as it would not significantly increase sodium levels. Hypertonic saline solutions are more appropriate for severe cases of hyponatremia.
C. Dextrose 5% in 0.45% sodium chloride: This solution is hypotonic and could worsen hyponatremia by diluting the sodium further. It should not be used to treat SIADH with severely low sodium levels.
D. 0.9% sodium chloride: Normal saline (0.9% sodium chloride) is isotonic and would not correct the low sodium levels as effectively as hypertonic saline. While it is used in less severe cases, 3% sodium chloride is necessary in cases of severe hyponatremia.
Correct Answer is C
Explanation
A. "You have many dangerously low blood sugar levels. A hemoglobin A1C of 9% indicates chronic hyperglycemia, not hypoglycemia. This test reflects an average blood glucose level over the past 2 to 3 months, and a high value suggests consistently elevated blood glucose, not frequent lows.
B. "Your blood sugar is too high after meals." While postprandial glucose spikes may contribute to an elevated A1C, the A1C reflects overall glycemic control, not just after meals. This statement is too narrow and doesn’t fully address the long-term trend that a 9% A1C represents.
C. "Your average blood sugar is high." This is the most accurate statement. A hemoglobin A1C of 9% correlates with an estimated average blood glucose level of approximately 212 mg/dL, which is well above the recommended target. It reflects poor long-term blood sugar control.
D. "Your blood sugar is very unstable." An A1C of 9% does not measure variability in blood sugar; it reflects a sustained elevation in average glucose. Blood sugar instability would be better evaluated with continuous glucose monitoring or frequent blood glucose checks, not A1C.
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