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 C
Explanation
Choice A rationale
Hyperthermia and severe tachycardia are not typical symptoms of damage to the parathyroid glands.
Choice B rationale
Hypercalcemia and shortness of breath are not typical symptoms of damage to the parathyroid glands.
Choice C rationale
Laryngospasms and tingling in the hands and feet can be symptoms of hypoparathyroidism, a condition that can occur if the parathyroid glands are damaged. Hypoparathyroidism can lead to low levels of calcium in the blood, which can cause these symptoms.
Choice D rationale
Hypophosphatemia, hypertension, vomiting, and chest pain are not typical symptoms of damage to the parathyroid glands.
Correct Answer is C
Explanation
Choice A rationale
While having a room within view of the nurses’ station can be beneficial for monitoring the patient, it does not specifically address the needs of a patient with active tuberculosis.
Choice B rationale
Placing a patient with active tuberculosis in a room with another non-surgical patient could potentially expose the other patient to the disease. Tuberculosis is an airborne disease and can easily spread to others in close proximity.
Choice C rationale
A room with air exhaust directly to the outdoor environment is the most appropriate choice for a patient with active tuberculosis. This type of room, known as a negative pressure room, helps prevent the spread of airborne diseases like tuberculosis. The air in the room is vented outside, reducing the risk of the disease spreading to other areas of the hospital.
Choice D rationale
While the ICU is equipped to handle severe and critical cases, a patient with active tuberculosis does not necessarily need to be in the ICU unless they are critically ill. Moreover, placing them in the ICU could potentially expose other critically ill patients to tuberculosis.
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