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.

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Correct Answer is A

Explanation

(A) Place the client in high-Fowler’s position and encourage the use of incentive spirometer and coughing: This is the most appropriate action. The high-Fowler’s position can help improve lung expansion and gas exchange, while the use of an incentive spirometer and coughing can help clear secretions and improve ventilation. This is particularly important for a client who is postoperative following an open thoracotomy.

(B) Switch oxygen to a nonrebreather mask: Switching to a nonrebreather mask may deliver a higher concentration of oxygen, but it does not address the underlying issue of impaired gas exchange due to decreased lung expansion and retained secretions.

(C) Position the client prone and have the respiratory therapist perform postural drainage: While postural drainage can help clear secretions, it may not be comfortable or safe for a client who is 1 day postoperative following an open thoracotomy.

(D) Increase oxygen to 70%: Increasing the oxygen concentration may improve the client’s oxygen saturation, but it does not address the underlying issue of impaired gas exchange due to decreased lung expansion and retained secretions. Furthermore, excessively high concentrations of oxygen can have harmful effects, such as oxygen toxicity or suppression of the respiratory drive in some clients.

A. "Report any incidents of swelling to your lips, tongue or face." B. "Report the development of a persistent dry cough." C. "Your cholesterol levels should be monitored monthly while taking this medication." D. "Make sure your diet contains a lot of potassium-rich foods" E. "Monitor your blood pressure on a regular basis."

Correct Answer is ["A","B","E"]

Explanation

A. "Report any incidents of swelling to your lips, tongue or face."

Angioedema is a serious side effect of lisinopril, which is an ACE inhibitor. Swelling of the lips, tongue, or face can indicate angioedema, which can be life-threatening and requires immediate medical attention.

B. "Report the development of a persistent dry cough."

A persistent dry cough is a common side effect of ACE inhibitors like lisinopril. If this occurs, the healthcare provider should be notified as an alternative medication may be needed.

C. "Your cholesterol levels should be monitored monthly while taking this medication."

Monitoring cholesterol levels is not typically necessary for clients taking lisinopril. This instruction is more relevant for medications affecting lipid levels, such as statins.

D. "Make sure your diet contains a lot of potassium-rich foods."

Lisinopril can cause hyperkalemia (high potassium levels). Therefore, it is important to avoid excessive intake of potassium-rich foods to prevent complications. Clients should be advised to monitor potassium intake rather than increase it.

E. "Monitor your blood pressure on a regular basis."

Regular monitoring of blood pressure is essential for clients taking lisinopril to ensure the medication is effectively managing their hypertension and to adjust dosages as necessary.

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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?

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