A female client who has been taking oral contraceptives for the past year comes into the clinic for an annual exam. Which finding is most important for the practical nurse (PN) to report to the healthcare provider?
Breast tenderness.
Left calf pain.
Change in menstrual flow.
Weight gain of 5 pounds (2.3 kg).
The Correct Answer is B
A. Breast tenderness is a common side effect of oral contraceptives and is generally not a cause for immediate concern unless accompanied by other symptoms.
B. Left calf pain is a significant finding that could indicate deep vein thrombosis (DVT), a serious condition requiring prompt evaluation and potential treatment to prevent complications such as pulmonary embolism.
C. A change in menstrual flow can occur with oral contraceptives but is usually less critical than other symptoms. It should be monitored but does not indicate an immediate problem.
D. A weight gain of 5 pounds is a relatively minor side effect and not as urgent as symptoms suggestive of a serious condition like DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering cholera vaccines can help prevent further cases but is not the immediate priority for those already infected.
B. Administering prophylactic antibiotics is important but not the highest priority compared to addressing the acute symptoms of cholera.
C. Isolating all infectious diarrhea victims helps prevent the spread of infection but does not address the immediate life-threatening dehydration and electrolyte imbalance.
D. Providing fluid and electrolyte replacement is the highest priority as cholera causes severe dehydration and electrolyte imbalance, which can be fatal if not treated promptly. Immediate rehydration is crucial to save lives.
Correct Answer is B
Explanation
A. Re-assessing the client’s temperature is important but not the priority action since the client is currently afebrile and the cough with yellow sputum could indicate an infection or other condition needing immediate attention.
B. Notifying the charge nurse of the assessment findings is the priority because the yellow-tinged sputum in a client receiving chemotherapy might indicate an infection or complication that requires further investigation and possible intervention.
C. Measuring and recording intake and output is important for overall fluid balance but does not address the immediate concern of a productive cough with potential infection.
D. Providing regular oral hygiene is part of general care but does not address the potential underlying cause of the productive cough and yellow-tinged sputum.
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