A client on bedrest complains of pain and burning in the right calf area. What is the nurse's next action?
Deeply palpate the area for rebound tenderness
Percuss over the area for a change in tone
Compare the circumference to the left calf
Medicate the client for pain and reassess in 60 minutes
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "I will need to limit the number of fruit servings each day." is not a statement that indicates a correct understanding of the teaching, because it is irrelevant and inaccurate. Limiting the number of fruit servings each day is not a part of the lowpurine diet, as fruits are low in purine and do not affect the uric acid levels. Fruits are also beneficial for the health, as they provide vitamins, antioxidants, and fiber.
Choice B reason: "I should avoid eating liver and other organ meats." is a statement that indicates a correct understanding of the teaching, because it is relevant and accurate. Avoiding eating liver and other organ meats is a part of the lowpurine diet, as organ meats are high in purine and can increase the uric acid levels. Uric acid is a waste product that is formed when purine is broken down in the body. High uric acid levels can cause gout, which is a type of arthritis that occurs when uric acid crystals accumulate in the joints, causing pain, inflammation, and swelling.
Choice C reason: "I can drink only white wine." is not a statement that indicates a correct understanding of the teaching, because it is incorrect and misleading. Drinking only white wine is not a part of the lowpurine diet, as white wine is not low in purine and can increase the uric acid levels. Alcohol, in general, can interfere with the excretion of uric acid by the kidneys, and can also trigger or worsen the gout attacks. Therefore, people with gout should limit or avoid alcohol consumption, regardless of the type or color of the wine.
Choice D reason: "I should choose red meat instead of poultry." is not a statement that indicates a correct understanding of the teaching, because it is incorrect and misleading. Choosing red meat instead of poultry is not a part of the lowpurine diet, as red meat is not low in purine and can increase the uric acid levels. Red meat, such as beef, pork, or lamb, is high in purine and can aggravate the gout symptoms. Therefore, people with gout should limit or avoid red meat consumption, and choose poultry, fish, or plantbased proteins instead.
Correct Answer is C
Explanation
Choice A reason: Culturing the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a sterile technique.
Choice B reason: Applying topical ointment to the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Applying topical ointment to the wound is a procedure that involves applying a medication or a dressing to the wound site, which can help prevent or treat infection, inflammation, or pain. Applying topical ointment to the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a clean technique.
Choice C reason: Inspecting the wound and assessing the drainage is the nurse's priority assessment for this client, because it is the most urgent and relevant action. Inspecting the wound and assessing the drainage is a process that involves observing and measuring the wound site and the wound exudate, which can reveal the presence and severity of infection, injury, or healing. Inspecting the wound and assessing the drainage is an essential assessment, as it can guide the diagnosis, treatment, and evaluation of the client's condition.
Choice D reason: Calling the provider to initiate antibiotics is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Calling the provider to initiate antibiotics is a communication that involves reporting the client's situation and requesting a prescription for an antimicrobial agent, which can help fight or prevent infection. Calling the provider to initiate antibiotics is an important communication, but it should be done after inspecting the wound and assessing the drainage, and with the necessary data and documentation.
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