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

Dull, aching calf pain.

Positive Kernig's sign.

Soft, pliable calf muscle.

Positive Homan's sign.

None

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A: Dull, aching calf pain.

Choice A rationale:

Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT), which can occur postoperatively, especially after vascular surgery. This pain is often due to a blood clot forming in the deep veins of the leg.

Choice B rationale:

Positive Kernig's sign is associated with meningitis and not typically related to thrombus formation.

Choice C rationale:

Soft, pliable calf muscle is not indicative of a thrombus. A thrombus would more likely cause tenderness and swelling.

Choice D rationale:

Positive Homan's sign (pain in the calf upon dorsiflexion of the foot) can be an indicator of DVT, but it is less reliable than dull, aching calf pain.

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Correct Answer is A

Explanation

Choice A rationale:

Bananas are a good source of potassium, and the client's serum potassium level is low (3.1 mEq/L). Including potassium-rich foods like bananas in the diet can help raise the potassium level and prevent hypokalemia, which is a potential side effect of furosemide (a diuretic).

Choice B rationale:

Cheddar cheese is not a suitable choice for a client with low potassium levels. It is not a significant source of potassium and should not be the primary recommendation for addressing hypokalemia.

Choice C rationale:

Cabbage is not a good choice for increasing potassium intake. While it has some potassium, other fruits and vegetables like bananas are much richer sources of this essential electrolyte.

Choice D rationale:

White rice is not a high-potassium food and should not be the first choice for a client with low potassium levels.

A. Withhold the digoxin dose for decreased heart rate. B. Administer digoxin 0.25 mg. C. Administer digoxin 0.125 mg. D. Withhold the digoxin dose for elevated BP. .

Correct Answer is A

Explanation

Choice A rationale:

Withholding the digoxin dose for a decreased heart rate is the correct action. Digoxin is a medication used to treat heart failure, but it can lead to bradycardia (slow heart rate) as a side effect. In this scenario, the client's heart rate is already at 54 beats per minute, which is below the normal range. Administering digoxin could further slow the heart rate, potentially leading to dangerous bradycardia or heart block. Withholding the medication is essential to prevent this adverse event.

Choice B rationale:

Administering digoxin 0.25 mg is not the appropriate action in this case. The client's heart rate is already below the normal range, and giving the full dose of digoxin could further depress the heart rate and increase the risk of bradycardia. Withholding the medication is the safer course of action.

Choice C rationale:

Administering digoxin 0.125 mg is not recommended because the client's heart rate is already below the normal range. While a reduced dose may be considered in some situations, it's essential to withhold the medication and consult with the healthcare provider in this specific case, as the client's heart rate is significantly low.

Choice D rationale:

Withholding the digoxin dose for elevated BP is not the appropriate action. Digoxin is primarily used to treat heart failure by increasing the force of cardiac contractions. Elevated blood pressure is not an indication to withhold digoxin. The focus should be on addressing the low heart rate in this scenario. .

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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