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 {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.
B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.
C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.
D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.
Correct Answer is B
Explanation
A. Cooling the solution is not necessary and may cause discomfort to the client.
B. Using a syringe with a catheter allows for precise and controlled irrigation of the wound, helping to remove debris and promote healing.
C. Wearing a fresh pair of gloves for irrigation helps prevent contamination and reduces the risk of infection.
D. Administering analgesia may help manage pain during the procedure, but it is not directly related to the technique of wound irrigation.
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