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 C

Explanation

Answer: C. Weigh the client each morning after voiding

Rationale:

A. Encourage the client to gain 2.3 kg (5 lb) per week:
A weight gain goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safe and realistic. Gaining 2.3 kg (5 lb) weekly is too aggressive and may cause physical and psychological stress for the client.

B. Monitor the client for 15 min after meals:
Clients with anorexia nervosa are at risk for purging behaviors. Monitoring for only 15 minutes is insufficient. A 60-minute post-meal observation period is more appropriate to deter vomiting or excessive exercise.

C. Weigh the client each morning after voiding:
Daily weights, taken at the same time each morning after voiding and before eating, provide consistent and accurate data to monitor progress and detect manipulation or fluid shifts.

D. Reinforce teaching about healthy eating during meals:
Reinforcing education during meals can increase the client’s anxiety and resistance to eating. Teaching is best done separately from mealtimes to avoid associating eating with stress.

A. Respiratory alkalosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory acidosis

Correct Answer is C

Explanation

A nurse reviewing the laboratory results of a client who has DKA should identify that the client's ABG results of pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L indicate metabolic acidosis. Metabolic acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a low bicarbonate level (less than 22 mEq/L).

The other options are not correct.

a) Respiratory alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a low PaCO₂ (less than 35 mm Hg).

b) Metabolic alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a high bicarbonate level (greater than 26 mEq/L).

d) Respiratory acidosisis an acid-base imbalance characterized by a low pH (less than 7.35) and a high PaCO₂ (greater than 45 mm Hg).

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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 nurse is assisting with planning care for a newly admited client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory results of a client who has DKA. The client's ABG results are pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L. The nurse should identify that these values indicate which of the following acid-base imbalances?

Correct Answer is C

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?