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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
For a patient with hypoglycemia who has experienced a suspected seizure, the immediate intervention would be to administer IV 0.9% sodium chloride and 5% glucose (dextrose). This helps to quickly raise the patient’s blood glucose levels and manage the seizure.
Correct Answer is B
Explanation
Choice A rationale
Taking ibuprofen for eye discomfort after cataract surgery is not typically recommended. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding, which can be problematic after eye surgery.
Choice B rationale
Wearing dark glasses while outdoors is often recommended after cataract surgery. This is because the eyes can be sensitive to light after the procedure. Dark glasses can help to protect the eyes from bright light and reduce discomfort.
Choice C rationale
Itching in the operative eye is not typically a sign of a serious problem after cataract surgery. Some itching can be normal as the eye heals. However, severe pain, vision loss, or heavy discharge should be reported to the provider immediately.
Choice D rationale
Creamy white drainage is not an indication of infection. In fact, it could be a sign of a more serious problem, such as an eye infection. Any changes in vision, pain, redness, or discharge should be reported to the healthcare provider.
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