A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has

deep-vein thrombosis. Which of the following findings should the nurse expect in the aﬀected extremity?

Absent dorsal pedal pulse

Shiny, hairless skin

Irregular, bulging veins

Dull, aching pain

Answer and Explanation

The Correct Answer is D

Choice A:

An absent dorsal pedal pulse would indicate a vascular problem such as arterial occlusion, not a deep vein thrombosis (DVT). In the case of DVT, blood flow in the veins is obstructed, but the arterial pulse, which is related to arterial circulation, should remain intact unless there is a separate arterial issue. Therefore, absent pulses are not characteristic of DVT.

Choice B:

Shiny, hairless skin is a sign typically associated with chronic arterial insufficiency, not DVT. This skin change occurs when there is poor arterial blood flow, which leads to a lack of nourishment for the skin, causing it to become thin and shiny. In contrast, DVT affects the veins and does not usually cause these skin changes in the acute phase.

Choice C:

Irregular, bulging veins are indicative of varicose veins or chronic venous insufficiency, not a DVT. Varicose veins occur when the veins become swollen and twisted due to weak or damaged valves. DVT, on the other hand, involves the formation of a clot in the deep veins and does not typically cause the veins to bulge visibly, especially in the early stages.

Choice D:

Dull, aching pain is a common symptom associated with deep vein thrombosis. This pain typically occurs in the affected extremity and is often described as a constant, aching sensation. The pain can worsen with movement or standing and is due to the inflammation and obstruction caused by the blood clot in the deep veins. This is a hallmark sign of DVT, along with swelling and redness in the affected limb.

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Correct Answer is D

Explanation

A newly licensed nurse who is having difficulty finishing client care tasks during their shift should try to complete one task before moving on to the next. This can help the nurse stay focused and organized, and prevent them from becoming overwhelmed.

The other options are not recommended for time management.

a) Delegating complicated tasks to an RNmay not be appropriate or allowed, depending on the task and the nurse's scope of practice.

b) Documenting all client care at the end of the shiftcan lead to errors and omissions.

c) Performing quick tasks before time-consuming tasks may not be the most efficient use of time, as it can lead to unfinished tasks at the end of the shift.

A. Collect 2 mL of sputum in an emesis basin B. Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection. C. Swab the oropharynx with a sterile swab D. Refrigerate the specimen until the time of transport to the laboratory

Correct Answer is D

Explanation

Answer: D

Rationale:

A) Collect 2 mL of sputum in an emesis basin: Collecting sputum in an emesis basin is inappropriate for laboratory testing. The sputum should be collected directly into a sterile container to prevent contamination. This ensures that the culture and sensitivity results are accurate and reflect the client's true respiratory pathogens.

B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum sample is not recommended because it may alter the flora present in the sputum, leading to inaccurate culture results. Instead, the client should rinse their mouth with plain water to clear excess saliva or food debris.

C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx does not obtain sputum from the lungs but instead gathers a sample from the throat, which may not be reflective of lower respiratory infections. A proper sputum sample is produced through a deep cough to collect material directly from the lungs.

D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen helps to preserve its integrity by preventing the overgrowth of bacteria or other pathogens until it can be transported to the laboratory. Proper refrigeration ensures that the culture and sensitivity results remain accurate.

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A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has deep-vein thrombosis. Which of the following findings should the nurse expect in the aﬀected extremity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly licensed nurse is having difficulty finishing client care tasks during their shift. Which of the following techniques should the nurse plan to use to assist with time management?

Correct Answer is D

Explanation

A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has

deep-vein thrombosis. Which of the following findings should the nurse expect in the aﬀected extremity?