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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: This is not the best action because encouraging range of motion can worsen the symptoms and cause more damage to the nerves and blood vessels. Range of motion is the movement of the joints and muscles through their normal extent. Range of motion can help to prevent stiffness, contractures, and muscle atrophy, but it can also increase the swelling and pressure in the affected area, which can impair the circulation and sensation.

Choice B reason: This is not the best action because applying heat to the affected hand can worsen the symptoms and cause more damage to the tissues. Heat is the transfer of thermal energy from a warmer object to a cooler one. Heat can help to relax the muscles, reduce the pain, and increase the blood flow, but it can also increase the inflammation and edema in the affected area, which can compromise the oxygen and nutrient delivery to the tissues.

Choice C reason: This is the best action because removing the cast can decrease the pressure and restore the circulation and sensation to the affected area. A cast is a rigid device that immobilizes and protects a fractured or injured body part. A cast can help to align the bones, prevent displacement, and promote healing, but it can also cause complications, such as compartment syndrome, infection, or nerve damage. Compartment syndrome is a condition where the pressure inside the muscles increases to dangerous levels, causing severe pain, reduced blood flow, and tissue death. The nurse should remove the cast immediately and notify the physician if the client shows signs of compartment syndrome, such as numbness, tingling, pallor, coolness, or swelling.

Choice D reason: This is not the best action because raising the arm above the level of the heart can worsen the symptoms and cause more damage to the nerves and blood vessels. Raising the arm above the level of the heart can help to reduce the swelling and pain in the affected area, but it can also reduce the blood flow and oxygenation to the area, which can lead to ischemia, necrosis, or gangrene. The nurse should elevate the arm at or below the level of the heart and monitor the pulse, color, temperature, and sensation of the fingers.

A. Temperature: 101.3 degrees Fahrenheit B. Oxygen saturation: 97% on room air C. Respirations: 22 breaths per minute D. Purulent drainage E. Client ambulates 20 feet

Correct Answer is ["A","D"]

Explanation

Choice A reason: A temperature of 101.3 degrees Fahrenheit is a sign of fever, which is a common symptom of infection. Clients with AIDS have a weakened immune system and are more susceptible to opportunistic infections. Fever indicates that the body is trying to fight off an infection.

Choice B reason: An oxygen saturation of 97% on room air is within the normal range and does not indicate infection. Oxygen saturation measures the percentage of hemoglobin that is bound to oxygen in the blood. A low oxygen saturation may indicate respiratory problems, such as pneumonia, which is a common infection in clients with AIDS.

Choice C reason: A respiratory rate of 22 breaths per minute is slightly above the normal range of 12 to 20 breaths per minute, but it does not necessarily indicate infection. Respiratory rate may vary depending on factors such as activity level, stress, pain, or anxiety. A high respiratory rate may indicate respiratory distress, which could be caused by infection or other conditions.

Choice D reason: Purulent drainage is a thick, yellowgreen, or brown pus that indicates infection. It may come from a wound, an abscess, or a body cavity. Purulent drainage is a sign of inflammation and infection and should be reported to the health care provider.

Choice E reason: A client's ability to ambulate 20 feet is not related to infection. Ambulation is a measure of mobility and function and may be affected by factors such as pain, fatigue, or muscle weakness. Ambulation does not reflect the presence or absence of infection.

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A client on bedrest complains of pain and burning in the right calf area. What is the nurse's next action?

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