A nurse is contributing to the plan of care for a client who is 2 days postoperative and reports pain in their calf. Which of the following actions should the nurse include?
Monitor the client's pulse oximetry.
Instruct the client to massage the calf gently.
Maintain the leg in a dependent position while in bed.
Apply a cold compress to the client's calf.
The Correct Answer is A
Pain in the calf can be a potential symptom of deep vein thrombosis (DVT), which is a serious complication after surgery. Monitoring the client's pulse oximetry can help assess for signs of decreased oxygenation, which may indicate a possible clot or compromised circulation. A decrease in oxygen saturation can be an early indicator of a potential DVT-related complication, such as a pulmonary embolism. Monitoring the pulse oximetry can provide valuable information for timely intervention and management.
Instructing the client to massage the calf gently is not advisable without further assessment and evaluation. Massaging the calf can potentially dislodge a clot if one is present, leading to further complications. It is important to rule out DVT through appropriate diagnostic measures before providing specific instructions for calf massage.
Maintaining the leg in a dependent position while in bed can potentially worsen the symptoms and increase the risk of venous stasis. Elevating the affected leg, rather than maintaining it in a dependent position, can help improve venous return and reduce pain or swelling.
Applying a cold compress to the client's calf is not recommended without further assessment. Heat or cold therapy should be applied based on the underlying cause of the pain. In the case of potential DVT, applying a cold compress can increase vasoconstriction and potentially worsen the condition. It is essential to investigate the cause of the pain first and consult with the healthcare provider before initiating any specific therapies or interventions.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
Cotton underwear is recommended for individuals with UTIs because it allows better air circulation and helps keep the genital area dry. This can prevent the growth of bacteria and reduce the risk of further infection.
Drink orange juice daily for 3 to 4 weeks: While hydration is important for overall health, there is no specific recommendation to drink orange juice or any specific juice for the treatment of a UTI. It is generally recommended to increase fluid intake, particularly water, to help flush out the bacteria from the urinary system.
Take the prescribed antibiotic until manifestations are gone: This instruction is correct. It is important for the client to take the full course of the prescribed antibiotic as directed by their healthcare provider, even if symptoms improve before completing the entire course. This helps ensure complete eradication of the bacteria and reduces the risk of antibiotic resistance.
Restrict fluid intake to 1 L per day: Adequate fluid intake is important for UTI management as it helps flush out bacteria from the urinary system. Restricting fluid intake to 1 liter per day is not recommended and may not provide sufficient hydration. It is generally advised to drink plenty of water and other fluids throughout the day.
Correct Answer is A
Explanation
Maintaining confidentiality and protecting the privacy of clients is a fundamental responsibility of healthcare professionals.
When the nurse becomes aware of a conversation between APs that breaches this confidentiality, it is essential to intervene promptly.
The nurse should approach the APs and respectfully ask them to stop the conversation and remind them about the importance of maintaining client confidentiality.
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