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 A

Explanation

Delegating tasks involves assigning appropriate responsibilities to assistive personnel based on their level of training, competency, and scope of practice. Performing indwelling urinary catheter care is a task that can be safely delegated to an AP who has received proper training and demonstrated competency in this skill. The nurse should ensure that the AP is familiar with the facility's policies and procedures regarding catheter care and can perform the task safely and effectively.

Demonstrating how to use an incentive spirometer requires specialized knowledge and the ability to provide clear instructions. It is typically within the scope of practice of licensed healthcare professionals, such as nurses or respiratory therapists, who have the necessary expertise to properly educate and guide patients in using an incentive spirometer. This task should not be delegated to an AP.

Measuring and assessing the depth of a pressure injury requires clinical judgment and accurate evaluation, which falls within the scope of practice of a licensed nurse. It involves understanding wound assessment, proper technique for measuring depth, and interpreting the findings. This task should be performed by the nurse rather than an AP.

Changing the appliance on a new colostomy involves skills such as assessing the stoma, selecting the appropriate appliance, and ensuring proper application. This task requires specialized knowledge and training in stoma care, and it should be performed by a licensed nurse who has the expertise in managing ostomies. It should not be delegated to an AP.

A. Falls asleep 5 minutes after starting a feeding B. Has 3 wet diapers each day. C. Has a bowel movement every other day. D. Makes audible swallowing sounds.

Correct Answer is D

Explanation

The nurse should identify that the newborn is making audible swallowing sounds as an indication that they are breastfeeding eﬀectively. This indicates that the newborn is able to latch onto the breast and transfer milk eﬀectively.

a) Falling asleep 5 minutes after starting a feeding may indicate that the newborn is not getting enough milk.

b) Having 3 wet diapers each day is not enough for a 5-day-old newborn. A newborn should have at least 6 wet diapers per day.

c) Having a bowel movement every other day is not an indication of eﬀective breastfeeding. A breastfed newborn should have at least 3 bowel movements per day.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Correct Answer is A

Explanation

A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding eﬀectively?

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?