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 D

Explanation

A. Have the client place their head between their knees:

Placing the head between the knees may help alleviate symptoms of hyperventilation by promoting relaxation and reducing dizziness. This position can help increase venous return to the heart and improve cerebral blood flow, which may reduce symptoms associated with hyperventilation.

B. Plan to administer sodium bicarbonate to the client:

Sodium bicarbonate is not indicated for respiratory alkalosis. It is used to treat metabolic acidosis by increasing plasma bicarbonate levels. Administering sodium bicarbonate to a client with respiratory alkalosis may exacerbate the alkalosis by further increasing the pH of the blood.

C. Plan to administer insulin to the client:

Insulin administration is not indicated for respiratory alkalosis. Insulin is used to manage hyperglycemia in diabetes mellitus and does not address the underlying respiratory condition causing alkalosis.

D. Have the client breathe into a paper bag:

Breathing into a paper bag is a common intervention for managing hyperventilation associated with respiratory alkalosis. Rebreathing exhaled carbon dioxide helps increase carbon dioxide levels in the blood, which can reverse the alkalosis and alleviate symptoms of hyperventilation.

A. "I’ll breathe deeply and cough every 4 hours." B. "I’ll splint my incision with a pillow to cough." C. " I’ll start to use the incentive spirometer when I can get out of bed." D. " I’ll lie flat in bed to cough and deep breath."

Correct Answer is B

Explanation

(A) "I’ll breathe deeply and cough every 4 hours."
Deep breathing and coughing exercises should be done more frequently, typically every 1-2 hours while awake, to help prevent respiratory complications such as atelectasis and pneumonia.

(B) "I’ll splint my incision with a pillow to cough."
This statement indicates an understanding of the instructions. Splinting the incision with a pillow helps support the surgical site, reduces pain, and makes coughing more effective and less uncomfortable. This technique is important for clients to use to help clear secretions from the lungs postoperatively.

(C) "I’ll start to use the incentive spirometer when I can get out of bed."
The use of an incentive spirometer should begin as soon as possible, usually while the client is still in bed, to encourage deep breathing and prevent postoperative respiratory complications. It should not be delayed until the client can get out of bed.

(D) "I’ll lie flat in bed to cough and deep breathe."
Lying flat is not the optimal position for deep breathing and coughing exercises, as it can make it more difficult to fully expand the lungs. The client should be positioned with the head of the bed elevated or sitting up to facilitate better lung expansion and more effective coughing.

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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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