A nurse is caring for a patient who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?
Consumed 35% of meals for 12 hr.
Been on bedrest for 3 days.
Last bowel movement 2 days ago.
Reports pain as 5 on a scale of 0 to 10.
The Correct Answer is D
Choice A rationale
While nutrition is important for recovery, consuming 35% of meals for 12 hours is not an immediate concern. The patient’s nutritional status can be addressed after more urgent issues are resolved.
Choice B rationale
Bedrest for 3 days post-surgery is not uncommon. While prolonged bedrest can lead to complications such as deep vein thrombosis, it is not the most immediate concern in this scenario.
Choice C rationale
A last bowel movement 2 days ago is not necessarily a concern unless the patient is experiencing discomfort or other symptoms of constipation. This can be addressed after more urgent issues are resolved.
Choice D rationale
This is the correct answer. Pain in the lower extremities following surgery could indicate a serious condition such as a blood clot. It is important to address this first to rule out any serious complications.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
While acetaminophen can be used to relieve discomfort, it should be used with caution in patients with liver disease like cirrhosis, as it can potentially cause further liver damage.
Choice B rationale
Patients with cirrhosis, especially those with ascites, are often advised to limit their sodium intake. High-sodium foods can contribute to fluid retention and worsen ascites. Therefore, avoiding high-sodium foods such as canned soups/vegetables, processed meats, and prepackaged frozen dinners is a key part of managing cirrhosis.
Choice C rationale
While maintaining adequate nutrition is important in cirrhosis, eating three large meals per day is not typically recommended. Instead, smaller, more frequent meals are often suggested.
Choice D rationale
While physical activity is generally beneficial, patients with cirrhosis and particularly those with complications such as ascites or encephalopathy may need to modify their activity levels based on their symptoms and overall health.
Correct Answer is B
Explanation
Choice A rationale
While a hiatal hernia can cause discomfort and other symptoms, it does not directly increase the risk for stomach cancer.
Choice B rationale
A hiatal hernia might increase your risk for Gastroesophageal Reflux Disease (GERD). This is because the hernia can cause the lower esophageal sphincter to malfunction, allowing stomach acid to flow back into the esophagus, which is the main cause of GERD1.
Choice C rationale
A hiatal hernia does not directly increase the risk for lung disease. However, if the hernia is large, it could potentially cause breathing difficulties or exacerbate existing respiratory conditions.
Choice D rationale
A hiatal hernia does not increase the risk for intestinal cancer. The hernia occurs in the diaphragm, which is separate from the intestines.
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