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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Let's calculate how many tablets the nurse should administer:
Dosage prescribed: The doctor prescribed digoxin 0.25 mg.
Tablet strength: Each available tablet contains 0.125 mg of digoxin.
To find out how many tablets are needed, we can divide the prescribed dosage by the amount of digoxin per tablet:
Number of tablets = Prescribed dosage / Amount of digoxin per tablet
Number of tablets = 0.25 mg / 0.125 mg/tablet
Since we might get a decimal result due to the division, we need to round to the nearest whole number of tablets the nurse can administer for safety reasons.
In this case, dividing 0.25 mg by 0.125 mg/tablet gives us 2.
Therefore, rounding up to the nearest whole number of tablets, the nurse should administer 2 tablets.
Correct Answer is D
Explanation
A. Vomiting:
Vomiting can lead to metabolic alkalosis due to the loss of hydrochloric acid from the stomach, resulting in increased bicarbonate levels in the blood. It does not directly contribute to metabolic acidosis.
B. Hyperventilation:
Hyperventilation can lead to respiratory alkalosis due to excessive elimination of carbon dioxide (CO2) through increased respiratory rate and depth. It is not associated with metabolic acidosis.
C. Diarrhea:
Diarrhea can lead to metabolic acidosis due to the loss of bicarbonate-rich fluid from the gastrointestinal tract, resulting in decreased bicarbonate levels in the blood. While diarrhea can contribute to metabolic acidosis, it is not the case in this scenario.
D. Salicylate intoxication:
Salicylate intoxication, such as aspirin overdose, can lead to metabolic acidosis due to the accumulation of salicylic acid, which is a weak acid that dissociates in the body, contributing to an increased anion gap metabolic acidosis. This is a direct cause of metabolic acidosis in this scenario.
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