A nurse is caring for a client who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?

Reports pain as 5 on a scale of 0 to 10

Been on bedrest for 3 days

Last bowel movement 2 days ago

Consumed 35% of meals for 12 hr

Answer and Explanation

The Correct Answer is B

A. "Reports pain as 5 on a scale of 0 to 10": While pain is an important concern, it is not the most immediate issue in this case. The nurse should first assess for factors that could contribute to complications or more severe issues.
B. "Been on bedrest for 3 days": Prolonged bedrest increases the risk of complications such as deep vein thrombosis (DVT), pulmonary embolism, or muscle atrophy. This is the priority because the client may be at risk for serious complications due to immobility.
C. "Last bowel movement 2 days ago": While constipation can cause discomfort, it is not as urgent as the risk posed by prolonged bedrest. This issue can be addressed once other more serious complications have been ruled out.
D. "Consumed 35% of meals for 12 hr": Poor nutrition is important to monitor, but it is not the immediate concern in this case. The focus should be on potential complications related to immobility, such as clot formation or respiratory issues.

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Correct Answer is C

Explanation

A. "You have many dangerously low blood sugar levels. A hemoglobin A1C of 9% indicates chronic hyperglycemia, not hypoglycemia. This test reflects an average blood glucose level over the past 2 to 3 months, and a high value suggests consistently elevated blood glucose, not frequent lows.
B. "Your blood sugar is too high after meals." While postprandial glucose spikes may contribute to an elevated A1C, the A1C reflects overall glycemic control, not just after meals. This statement is too narrow and doesn’t fully address the long-term trend that a 9% A1C represents.
C. "Your average blood sugar is high." This is the most accurate statement. A hemoglobin A1C of 9% correlates with an estimated average blood glucose level of approximately 212 mg/dL, which is well above the recommended target. It reflects poor long-term blood sugar control.
D. "Your blood sugar is very unstable." An A1C of 9% does not measure variability in blood sugar; it reflects a sustained elevation in average glucose. Blood sugar instability would be better evaluated with continuous glucose monitoring or frequent blood glucose checks, not A1C.

A. "Distributive shock occurs due to loss of myocardial contractility." B. "Distributive shock occurs due to systemic vasodilation." C. "Distributive shock occurs due to loss of blood volume." D. "Distributive shock occurs due to increased systemic vascular resistance."

Correct Answer is B

Explanation

A. Distributive shock occurs due to loss of myocardial contractility: Loss of myocardial contractility is more associated with cardiogenic shock, not distributive shock. Distributive shock occurs due to vasodilation, which leads to inadequate perfusion despite normal heart function.
B. Distributive shock occurs due to systemic vasodilation: Distributive shock is characterized by widespread vasodilation, often resulting from conditions such as sepsis, anaphylaxis, or neurogenic shock. This vasodilation leads to a decrease in vascular resistance, causing poor blood flow and oxygen delivery to tissues.
C. Distributive shock occurs due to loss of blood volume: Loss of blood volume is characteristic of hypovolemic shock, not distributive shock. In hypovolemic shock, blood volume is reduced, whereas in distributive shock, the issue lies in vascular tone and vasodilation.
D. Distributive shock occurs due to increased systemic vascular resistance: In distributive shock, systemic vascular resistance decreases due to vasodilation, not increases. The decrease in vascular tone is what leads to the impaired tissue perfusion seen in this form of shock.

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A nurse is caring for a client who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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