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 D

Explanation

A. Decreased urinary sodium: In SIADH, urinary sodium is typically not decreased. The kidneys continue to excrete sodium even in the presence of low serum sodium, due to the inappropriate retention of water. This results in normal or elevated urinary sodium levels, making decreased urinary sodium inconsistent with SIADH.
B. Increased serum sodium: SIADH is characterized by the retention of free water, which leads to dilutional hyponatremia, not hypernatremia. The excess water dilutes sodium concentration in the blood, resulting in decreased rather than increased serum sodium. Elevated serum sodium would suggest dehydration or another endocrine issue.
C. Decreased urine osmolality: In SIADH, the kidneys respond to the high levels of antidiuretic hormone by concentrating the urine. As a result, urine osmolality is typically elevated, not decreased. Dilute urine would be more consistent with diabetes insipidus rather than SIADH.
D. Decreased serum osmolality: This is a key diagnostic feature of SIADH. The excessive release of ADH causes the body to retain water, which dilutes the blood and lowers serum osmolality. This dilutional effect also contributes to hyponatremia and associated neurological symptoms.

A. Notify the rapid response team due to the client’s clinical signs of a tension pneumothorax B. Reassure the client and administer prescribed analgesics for pain relief C. Encourage the client to take deep breaths and use incentive spirometry D. Elevate the head of the bed and increase oxygen to 4 L/min via nasal cannula E. Document the findings and re-evaluate in 15 minutes

Correct Answer is A

Explanation

A. Notify the rapid response team due to the client’s clinical signs of a tension pneumothorax: The client presents with acute right-sided chest pain, dyspnea, hypotension, unilateral decreased breath sounds, hyperresonance, and agitation—classic signs of a tension pneumothorax, a life-threatening emergency requiring immediate intervention. Rapid response activation ensures rapid access to advanced airway and chest decompression support.
B. Reassure the client and administer prescribed analgesics for pain relief: The pain is a symptom of a serious underlying condition—possibly a collapsed lung. Administering pain medication could delay life-saving intervention.
C. Encourage the client to take deep breaths and use incentive spirometry: This intervention is appropriate for postoperative atelectasis, but it is contraindicated in tension pneumothorax. Increasing intrathoracic pressure through deep breaths may worsen the pneumothorax.
D. Elevate the head of the bed and increase oxygen to 4 L/min via nasal cannula: While increasing oxygen and elevating the head can help improve oxygenation, they do not treat the underlying cause. These supportive measures may be used after emergency intervention has been initiated.
E. Document the findings and re-evaluate in 15 minutes: Delaying intervention in this situation is unsafe. A tension pneumothorax can rapidly lead to cardiovascular collapse, so waiting even a few minutes may result in deterioration or death.

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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?

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