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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An elevated serum calcium level (hypercalcemia) can indicate a complication of total parenteral nutrition, such as hypercalcemia resulting from excess calcium supplementation in the
TPN solution, which can lead to complications such as renal calculi and cardiac dysrhythmias.
B. The blood urea nitrogen (BUN) level within the normal range does not indicate a complication related to total parenteral nutrition.
C. The serum potassium level within the normal range does not indicate a complication related to total parenteral nutrition.
D. A normal white blood cell (WBC) count does not indicate a complication related to total parenteral nutrition.
Correct Answer is C
Explanation
A. Incorrect. While proper spacing of infant bassinets is important for infection control, this specific distance (24 inches) may not be universally applicable and may vary depending on the facility's protocols.
B. Incorrect. Alcohol-based hand rubs are recommended for hand hygiene in healthcare settings, as they are effective against a broad range of pathogens. They should not be avoided unless contraindicated due to specific circumstances.
C. Correct. Visitors with upper respiratory infections can spread respiratory viruses to vulnerable newborns, so wearing a mask can help prevent transmission.
D. Incorrect. Pumped breastmilk can typically be left at room temperature for a shorter duration, usually up to 4 hours, to maintain its safety and quality.
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