B SN 266 Per ioper ative ISB case
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A 45-year-old male client had a partial colectomy with descending
colostomy secondary to colon cancer 3 days ago. The client had a
history of colorectal polyps and ulcerative colitis and a body mass
index (BMI) of 42. He is married and has three children, works as
a computer programmer, and was independent prior to surgery.
The shift report indicates that the client had a difficult recovery
after surgery and has been on bedrest since admission.
which client statements require a follow-up assessment by the
nurse? select all that apply - answer " My right leg seems skinner
than my left leg, which is warm and swollen"
"I have pain in my left calf. it's tolerable but I would rate it as a 4
on a scale of 0 to 10."
, The nurse is concerned that the client may had a blood clot and
performs an assessment of the left lower extremity (LLE). For
each finding below, identify if the finding is consistent with the
present of an arterial thrombus or a deep vein thrombosis (DVT).
- answer arterial thrombus:
-left extremity is pale when elevates on pillows.
-capillary refill=more than 3 seconds.
DVT
-dull ache or heaviness in the left calf
-peripheral pulses are difficult to palpate because of pitting edema
The nurse's focused assessment finding are consistent with
venous thromboembolism and include unilateral lower extremity
pitting edema and pain. Venous duplex ultrasonography confirms
the client has a left lower extremity deep vein thrombosis. For
each finding below, indicate if the nursing action is indicated
(appropriate or necessary), contraindicated (could be harmful), or
non-essential (makes no difference or is not necessary) for the
client's care at this time. - answer indicated:
-apply sequential compression device to unaffected lower
extremity
-instruct the client to gradually increase activity and to stop any
activity temporarily if pain occurs.
contraindicated:
study latest updated ver sion
w ith exper t cur ated questions
and answ er s | GUARANTEED
SUCCESS
A 45-year-old male client had a partial colectomy with descending
colostomy secondary to colon cancer 3 days ago. The client had a
history of colorectal polyps and ulcerative colitis and a body mass
index (BMI) of 42. He is married and has three children, works as
a computer programmer, and was independent prior to surgery.
The shift report indicates that the client had a difficult recovery
after surgery and has been on bedrest since admission.
which client statements require a follow-up assessment by the
nurse? select all that apply - answer " My right leg seems skinner
than my left leg, which is warm and swollen"
"I have pain in my left calf. it's tolerable but I would rate it as a 4
on a scale of 0 to 10."
, The nurse is concerned that the client may had a blood clot and
performs an assessment of the left lower extremity (LLE). For
each finding below, identify if the finding is consistent with the
present of an arterial thrombus or a deep vein thrombosis (DVT).
- answer arterial thrombus:
-left extremity is pale when elevates on pillows.
-capillary refill=more than 3 seconds.
DVT
-dull ache or heaviness in the left calf
-peripheral pulses are difficult to palpate because of pitting edema
The nurse's focused assessment finding are consistent with
venous thromboembolism and include unilateral lower extremity
pitting edema and pain. Venous duplex ultrasonography confirms
the client has a left lower extremity deep vein thrombosis. For
each finding below, indicate if the nursing action is indicated
(appropriate or necessary), contraindicated (could be harmful), or
non-essential (makes no difference or is not necessary) for the
client's care at this time. - answer indicated:
-apply sequential compression device to unaffected lower
extremity
-instruct the client to gradually increase activity and to stop any
activity temporarily if pain occurs.
contraindicated:
