A nurse is collecting data from a client who is 24 hr postoperative following a total knee arthroplasty. Which of the following findings on the operative leg should the nurse identify as a manifestation of a deep-vein thrombosis?

Increase in calf size

Capillary refill of 2 seconds

Palpable cord-like vein

Extremity feels cool to the touch

Answer and Explanation

The Correct Answer is C

A.   An increase in calf size can be a sign of deep-vein thrombosis (DVT), but it is not specific to
DVT and can occur with other conditions such as edema.
B.   Capillary refill of 2 seconds is within the expected range and is not indicative of DVT.
C.   A palpable cord-like vein is a classic sign of DVT and should be further assessed and reported for appropriate intervention.
D.   An extremity feeling cool to the touch can be a sign of impaired circulation but is not specific to DVT and can occur with other vascular conditions.

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Correct Answer is D

Explanation

A. Hypernatremia: Hypernatremia (elevated sodium levels) is not typically associated with the emergent phase of burn injuries.
B. Hypercalcemia: Hypercalcemia (elevated calcium levels) is not typically associated with the emergent phase of burn injuries.
C. Hypermagnesemia: Hypermagnesemia (elevated magnesium levels) is not typically associated with the emergent phase of burn injuries.
D. Hyperkalemia: Hyperkalemia (elevated potassium levels) is a common electrolyte imbalance seen in the emergent phase of burn injuries due to the release of potassium from damaged cells.
It can lead to cardiac dysrhythmias and other complications if not promptly addressed.

A. A client who has a new onset of chest pain B. A client who has a tracheostomy C. A client who is receiving enteral feedings D. A client who has urinary retention

Correct Answer is A

Explanation

A. A client who has a new onset of chest pain requires immediate assessment and intervention by an RN or healthcare provider with appropriate training and licensure due to the potential seriousness of the condition. Assessing and managing chest pain typically involves performing an ECG, administering medications, and coordinating further diagnostic tests or interventions, which are typically within the scope of practice of an RN or higher.
B. A client who has a tracheostomy may require routine tracheostomy care and suctioning, which are within the scope of practice of an LPN under the supervision of an RN or healthcare provider.
C. A client who is receiving enteral feedings may require monitoring of feeding tube placement, administration of enteral feedings, and assessment for complications related to enteral nutrition, which are within the scope of practice of an LPN.
D. A client who has urinary retention may require urinary catheterization or bladder scan assessment, which are within the scope of practice of an LPN under the supervision of an RN or healthcare provider.

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A nurse is collecting data from a client who is 24 hr postoperative following a total knee arthroplasty. Which of the following findings on the operative leg should the nurse identify as a manifestation of a deep-vein thrombosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is reviewing client care assignments prior to the beginning of a shift. Which of the following client assignments should the nurse identify as being outside the scope of practice for an LPN?

Correct Answer is A

Explanation

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