A nurse is assessing a client whose therapy has included bed rest for several weeks.
Which of the following findings should the nurse identify as the priority?
Loss of appetite
Left lower extremity tenderness
Increased heart rate during physical activity
Musculoskeletal weakness
The Correct Answer is B
A. While decreased appetite may be concerning, it is not typically considered a priority over potential complications related to immobility.
B. Left lower extremity tenderness could indicate deep vein thrombosis (DVT), a serious complication of prolonged bed rest that requires immediate attention to prevent pulmonary embolism.
C. Increased heart rate during physical activity may be expected after a period of bed rest and can be addressed with gradual reconditioning.
D. Musculoskeletal weakness is a common consequence of immobility and would be addressed as part of the client's rehabilitation but is not an immediate priority compared to potential complications like DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While it may be necessary to notify risk management eventually, the immediate priority is to ensure the client's safety and well-being.
B. The nurse should promptly assess the client for signs and symptoms of an allergic reaction and initiate appropriate interventions as necessary.
C. Documentation of the medication error and allergic reaction should be completed after ensuring the client's immediate needs are addressed.
D. Administering an antidote may be appropriate in certain situations, but the nurse should first assess the client's condition and follow established protocols for managing allergic reactions.
Correct Answer is C
Explanation
A. While educating the client about the benefits of surgery is important, it is not appropriate to dismiss the client's concerns in this situation.
B. It is important to respect the client's autonomy and decision-making process. If the client expresses a desire to reconsider the surgery, their wishes should be respected.
C. The nurse should respect the client's decision and communicate their wishes to the surgical team for further discussion and decision-making.
D. While reassurance is important, it should be provided in a way that acknowledges and respects the client's concerns and decisions.
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