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
Choice A rationale
While assessing the client’s skin for a rash could be part of the overall assessment of the client’s condition, it is not the priority action when a client is experiencing chills and back pain during a blood transfusion.
Choice B rationale
Notifying the provider is an important step when a client is experiencing a reaction to a blood transfusion, but it is not the first action that should be taken.
Choice C rationale
Covering the client with a blanket may provide comfort to the client, but it does not address the underlying issue of a potential transfusion reaction.
Choice D rationale
The priority action when a client is experiencing chills and back pain during a blood transfusion is to stop the transfusion. This is because these symptoms could indicate a transfusion reaction, which can be serious.
Correct Answer is A
Explanation
Choice A rationale
Patients with a nasogastric (NG) tube to suction are at risk for hypokalemia. Hypokalemia, or low potassium levels, can occur due to increased losses from the gastrointestinal tract, which can occur with NG tube suction. Potassium is an essential electrolyte that plays a vital role in many bodily functions, particularly in the heart and cardiovascular system. Therefore, any condition or intervention that leads to a significant loss of potassium, such as NG tube suction, can potentially lead to hypokalemia.
Choice B rationale
A tracheostomy tube attached to humidified oxygen is primarily used to help a patient breathe. It does not typically contribute to potassium loss or imbalance. Therefore, it is not likely to increase the risk of hypokalemia.
Choice C rationale
An indwelling urinary catheter to gravity drainage is used to drain urine from the bladder. While the kidneys do play a role in maintaining potassium balance, the use of a urinary catheter itself does not typically lead to significant potassium loss or increase the risk of hypokalemia.
Choice D rationale
A chest tube to water seal is used to remove air, fluid, or pus from the pleural space to help the lungs expand properly. It does not typically contribute to potassium loss or imbalance.
Therefore, it is not likely to increase the risk of hypokalemia.
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