A nurse is caring for a client who is postoperative following cardiac surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

Positive Kernig's sign

Dull, aching calf pain

Soft, pliable calf muscle

Positive Homan's sign

Answer and Explanation

Correct Answer : B,D

A. Positive Kernig's sign:

Positive Kernig's sign is associated with meningitis, not thrombosis. It is a clinical sign where pain is elicited when the hip is flexed at a 90-degree angle and then the knee is extended. This sign is not relevant for identifying a thrombus.

B. Dull, aching calf pain:

Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT). Pain, swelling, and tenderness in the calf are typical manifestations of a thrombus in the leg veins. This symptom should alert the nurse to the possibility of a thrombus.

C. Soft, pliable calf muscle:

A soft, pliable calf muscle is not indicative of a thrombus. In the case of DVT, the affected leg is usually swollen, firm, and tender. Thus, this manifestation does not suggest the presence of a thrombus.

D. Positive Homan's sign:

Positive Homan's sign is identified when there is pain in the calf upon dorsiflexion of the foot. This sign can be indicative of DVT. Although not highly specific or sensitive, it is one of the traditional signs used to assess for the presence of a thrombus in the leg.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Small for gestational age:

While being small for gestational age can contribute to respiratory difficulties in newborns, it is not directly associated with respiratory distress syndrome or respiratory acidosis. Other factors, such as prematurity or intrauterine growth restriction, may play a more significant role.

B. Cesarean birth:

Cesarean birth can predispose newborns to respiratory difficulties, including respiratory distress syndrome. During vaginal birth, the compression of the chest during passage through the birth canal helps expel lung fluid, whereas babies born via cesarean section may have more retained lung fluid, leading to respiratory distress.

C. Ventricular septal defect:

Ventricular septal defect is a congenital heart defect and is not directly associated with respiratory distress syndrome or respiratory acidosis. However, congenital heart defects can affect the cardiovascular system, leading to respiratory compromise in some cases.

D. Maternal history of asthma:

While maternal asthma can increase the risk of respiratory problems in newborns, it is not directly related to respiratory distress syndrome or respiratory acidosis. Maternal asthma may increase the likelihood of the newborn developing asthma or other respiratory conditions later in life.

A. Increase in postoperative pain B. Reduced postoperative anxiety C. Reduced postoperative respiratory function D. Increased length of postoperative care in the health care facility

Correct Answer is B

Explanation

A. Increase in postoperative pain: Preoperative teaching typically includes information about pain management strategies, which should help to reduce, not increase, postoperative pain.

B. Reduced postoperative anxiety: This is correct. One of the key benefits of preoperative education is reduced anxiety. By understanding what to expect before, during, and after surgery, patients are often less anxious about the procedure.

C. Reduced postoperative respiratory function: Preoperative teaching usually includes instructions on deep breathing and coughing exercises to help prevent respiratory complications after surgery. Therefore, it should improve, not reduce, postoperative respiratory function.

D. Increased length of postoperative care in the health care facility: Preoperative education has been shown to reduce the length of hospital stay. By better understanding their surgery and postoperative care, patients are often able to recover more quickly and leave the hospital sooner

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is postoperative following cardiac surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. Which of the following risk factors predisposes the newborn to respiratory difficulties?

Correct Answer is B

Explanation

A nurse is assisting with preoperative teaching for a client. Which of the following outcomes should the nurse expect?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

A nurse is planning to use the nursing process to care for a client who is experiencing grief. Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client who was admitted to the cardiac telemetry unit after he experienced chest pain, dyspnea and diaphoresis. Which of the following electrocardiogram (ECG) findings is a manifestation of acute myocardial infarction?

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?

A nurse is preparing to administer digoxin 0.25 mg PO to a client. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer to the client? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is reinforcing preoperative teaching with a client who is to undergo a bowel resection at 1300 next week. Which of the following statements client indicates to the nurse a need for further teaching?