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
The Correct Answer is C
c. Irregular, bulging veins
Deep-vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in the deep veins, commonly in the lower extremities. When assessing a client with DVT, the nurse should expect to find irregular, bulging veins in the affected extremity. This is due to the obstruction of blood flow caused by the clot, leading to distension and visible changes in the appearance of the veins.
Explanation for the other options:
a. Absent dorsal pedal pulse: Absent dorsal pedal pulse is not a characteristic finding of DVT. It may be associated with peripheral arterial disease, which is a different condition involving impaired blood flow in the arteries.
b. Shiny, hairless skin: Shiny, hairless skin is not a typical finding in the affected extremity with DVT. In fact,
the skin in the area of the clot may appear red, warm to touch, and swollen.
d. Dull, aching pain: Dull, aching pain may be present in the affected extremity with DVT. However, it is important to note that some individuals with DVT may not experience any pain or may have minimal discomfort. Therefore, the absence of pain does not rule out the possibility of DVT.
In summary, irregular, bulging veins are an expected finding in the affected extremity of a client with deep- vein thrombosis (DVT). It is important for the nurse to recognize and report these signs promptly to facilitate appropriate management and prevention of complications associated with DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A nurse admitting a client who has active tuberculosis should place the client in a room that is ventilated to
the outside. This is an appropriate nursing intervention to prevent the spread of tuberculosis to others.
The other options are not correct.
b) The nurse does not need to wear a gown when delivering the client's food tray but should wear a mask and gloves.
c) Visitors are not prohibited while the client's infection is activebut should be limited and should wear masks.
d) A tuberculin skin test is not necessary prior to discharge as the client has already been diagnosed with active tuberculosis.
Correct Answer is C
Explanation
a. "Start the first patch on the seventh day of the menstrual cycle."
Explanation:
The correct answer is a. "Start the first patch on the seventh day of the menstrual cycle."
When providing teaching about a combination contraceptive transdermal patch, it is important to provide accurate and relevant information to ensure its effectiveness and proper use.
Option b is not the correct answer. The contraceptive effect of the transdermal patch does not continue for 6 months following discontinuation. Its effectiveness lasts only as long as the client continues to use it according to the prescribed schedule.
Option c is not the correct answer. The transdermal patch should be applied to a clean, dry area of the skin that is free from cuts, rashes, or irritation. The lower abdomen is not a recommended site for application.
Option d is not the correct answer. While headaches can occur as a side effect of hormonal contraceptives, it is not necessary to expect a headache during the first month. Side effects can vary among individuals, and it is important to monitor and report any concerning symptoms to the healthcare provider.
By instructing the client to start the first patch on the seventh day of the menstrual cycle, the nurse provides specific guidance on when to initiate the contraceptive method. This ensures that the client is starting the patch at an appropriate time in their menstrual cycle, optimizing its effectiveness
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