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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A client statement that indicates an understanding of discharge teaching for type 1 diabetes mellitus is "I will dispose of insulin needles in a puncture-proof container." This is the correct way to dispose of insulin needles to prevent accidental needle sticks.
The other options are not correct.
b) Opened insulin vials do not need to be stored in the refrigerator, but should be kept at room temperature.
c) Insulin vials should not be shakenas this can cause the insulin to break down.
d) Regular insulin should appear clear, not cloudy.
Correct Answer is D
Explanation
Answer: (D) A client has the right to view their medical record
Rationale:
A) The actual medical record belongs to the client: While clients have the right to access their medical records, the physical medical record itself typically belongs to the healthcare provider or facility that created it. The client does not own the physical document but has the right to view or obtain copies of it under HIPAA regulations.
B) A client's medical record information remains confidential, even during an emergency: While confidentiality is a core principle of the HIPAA Privacy Rule, there are specific exceptions during emergencies. For instance, healthcare providers may share information if it is necessary to provide care or if there is an imminent threat to the client or others. Thus, confidentiality can be adjusted in critical situations.
C) If the client dies, their family receives their medical record: A client’s medical records do not automatically go to their family after death. Access to a deceased person's medical records is typically granted to the executor of the estate or a legal representative, and specific legal processes must be followed. Therefore, this statement is incorrect.
D) A client has the right to view their medical record: Under the HIPAA Privacy Rule, clients have the right to access and view their medical records. They can request copies of their records, review them, and request amendments if they believe there are errors. This right is fundamental to ensuring transparency and accuracy in medical documentation.
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