A client is recovering from a fractured radius that occurred 8 weeks ago. In which stage of bone healing is the callus resorbed and transformed into bone?

Choice A reason: Deeply palpating the area for rebound tenderness is not the nurse's next action, because it is inappropriate and dangerous. Deeply palpating the area for rebound tenderness is a test that involves applying and releasing pressure on the abdomen, which can elicit pain or discomfort in the presence of peritonitis or appendicitis. Deeply palpating the area for rebound tenderness is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Deeply palpating the area for rebound tenderness can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.

Choice B reason: Percussing over the area for a change in tone is not the nurse's next action, because it is inappropriate and useless. Percussing over the area for a change in tone is a test that involves tapping on the chest or abdomen, which can produce different sounds depending on the density of the underlying organs or tissues. Percussing over the area for a change in tone is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Percussing over the area for a change in tone can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.

Choice C reason: Comparing the circumference to the left calf is the nurse's next action, because it is appropriate and useful. Comparing the circumference to the left calf is a test that involves measuring the size of the leg, which can reveal any swelling or edema in the affected area. Comparing the circumference to the left calf is relevant and useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Comparing the circumference to the left calf can also help diagnose, monitor, or treat the condition, as a difference of more than 2 cm between the legs can suggest a DVT.

Choice D reason: Medicating the client for pain and reassessing in 60 minutes is not the nurse's next action, because it is inappropriate and delayed. Medicating the client for pain and reassessing in 60 minutes is an intervention that involves giving the client a painkiller and checking the response after an hour. Medicating the client for pain and reassessing in 60 minutes is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Medicating the client for pain and reassessing in 60 minutes can also mask the symptoms, delay the diagnosis, or miss the opportunity to prevent the complications, such as pulmonary embolism, which is a lifethreatening condition.

Choice A reason: Inflammation is not an example of a client's primary defense to infection. Inflammation is a secondary defense to infection, which is activated after the primary defense has been breached. Inflammation is a complex process that involves the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of exudate. Inflammation aims to contain, neutralize, and eliminate the infectious agent and to repair the damaged tissue.

Choice B reason: Fever is not an example of a client's primary defense to infection. Fever is a secondary defense to infection, which is activated after the primary defense has been breached. Fever is an elevation of the body temperature above the normal range, which is usually 36.5 to 37.5 degrees Celsius or 97.7 to 99.5 degrees Fahrenheit. Fever is a systemic response to infection that is regulated by the hypothalamus, which is the part of the brain that controls the body's thermostat. Fever enhances the immune system's activity and inhibits the growth of some pathogens.

Choice C reason: Phagocytosis is not an example of a client's primary defense to infection. Phagocytosis is a secondary defense to infection, which is activated after the primary defense has been breached. Phagocytosis is a process that involves the engulfment and destruction of foreign particles, such as bacteria, by specialized cells, such as macrophages and neutrophils. Phagocytosis is a type of cellular immunity that eliminates the infectious agent and prevents its spread.

Choice D reason: Intact skin is an example of a client's primary defense to infection. Intact skin is the first and most important line of defense against infection, as it forms a physical barrier that prevents the entry of pathogens into the body. Intact skin also has chemical and biological properties that resist infection, such as the acidic pH, the secretion of sebum and sweat, and the presence of normal flora. Intact skin protects the underlying tissues and organs from infection and injury.