The nurse is caring for a client who delivered vaginally 12 hours ...

[mmm]

The nurse is caring for a client who delivered vaginally 12 hours ago. The client reports pain in the left calf, and the nurse assesses an area of redness that is warm to touch and edematous.
 
  The nurse further confirms suspicions of thrombophlebitis by having the client: 1. Flex the ankle to check for a positive Babinski.
  2. Lay supine and elevate the leg, gradually extending it to check for Brudzinski sign.
  3. Point the toes to check for a positive Homans' sign.
  4. Stroke the cheek and check for a positive rooting reflex.

Question 2

The nurse is checking the tray of the postoperative client who advanced to a clear-liquid diet, and removes which of the following if found on the tray? Select all that apply. Standard Text: Select all that apply.
 
  1. Black cherry gelatin
  2. Coffee with creamer
  3. Tomato soup
  4. Orange Popsicle
  5. Ginger ale

[nikmaaacs]

Answer to Question 1

3
Rationale: Thrombophlebitis of the calf results in a positive Homans' sign, indicated by calf pain caused by flexing the toes.

Answer to Question 2

2,3
Rationale: Coffee creamer is not allowed on a clear-liquid diet. Black coffee is allowed. Tomato soup is not considered a clear liquid. A clear beef or chicken broth would be allowed. Gelatin, Popsicles, and ginger ale are considered clear liquids.

[mmm]

TYSM

[phuda]

Gracias!