A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis
Vital Signs
- Blood Pressure 130/72 mm Hg
- Heart rate 90/min
- Respiratory rate 18/min
- Temperature 37" C (98.6" F)
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each finding dick to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening
Leukocytosis
Redness in the extremity
Scant lochia rubra
Increased warmth in the extremity
Tachycardia
Decreased extremity edema
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"B"}}
Leukocytosis: Indication of Worsening Condition - Leukocytosis, an increase in white blood cell count, may indicate an exacerbation of the deep vein thrombosis or the development of an infection.
Redness in the extremity: Indication of Worsening Condition - Redness in the extremity suggests inflammation or worsening of the deep vein thrombosis.
Scant lochia rubra: Indication of Improving Condition - Scant lochia rubra indicates a decrease in postpartum bleeding, which is a positive sign.
Increased warmth in the extremity: Indication of Worsening Condition - Increased warmth in the extremity suggests increased inflammation and may indicate progression of the deep vein thrombosis.
Tachycardia: Indication of Worsening Condition - Tachycardia, an elevated heart rate, can be a sign of worsening condition, possibly due to complications such as pulmonary embolism.
Decreased extremity edema: Indication of Improving Condition - Decreased extremity edema suggests reduced swelling, which is a positive sign indicating improvement in circulation and reduction of fluid accumulation in the affected limb.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Provide the newborn with 15 ml glucose water after each feeding: This action is not directly related to phototherapy for jaundice treatment.
B. Turn the newborn every 4 hours: While turning the newborn is important for preventing pressure ulcers, it is not specifically related to phototherapy.
C. Close the newborn's eyes before applying eyepatches:
Correct answer. It is important to protect the newborn's eyes from phototherapy light by using eye patches or covering their eyes with soft material to prevent damage to the retina.
D. Apply hydrating lotion to the newborn's skin prior to treatment: Hydrating lotion is not typically applied before phototherapy, as it may interfere with the effectiveness of the treatment or cause skin irritation.
Correct Answer is B
Explanation
Rationale:
A. Determining the client's apical pulse rate is important for monitoring the effects of digoxin therapy but does not directly assess medication adherence.
B. Asking the client if they are taking the medication as prescribed is a direct way to evaluate medication adherence. Open communication with the client can provide valuable insight into their medication-taking behavior.
C. Assessing the client's kidney function is important for monitoring the effects of digoxin therapy but does not directly assess medication adherence.
D. Checking the client's serum medication level can provide information about medication concentration but may not necessarily indicate adherence, as the level could be within the therapeutic range even if the client is not taking the medication as prescribed.
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