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.

Answer and Explanation

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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Correct Answer is A

Explanation

a. "I should discuss this document with my family after I sign it"

Advance directives are legal documents that allow an individual to specify the type of medical care they want to receive in case they become unable to make their own decisions. It is important for the client to discuss their wishes with their family members or loved ones so that they are aware of the client's desires and can act accordingly in case of an emergency.

b. "I am not allowed to change my mind once I sign this document" is incorrect. The client can change their mind about their advance directive at any time and for any reason. It is important for the client to review their advance directive periodically and make changes as necessary.

c. "An atorney will need to notarize this document for it to be valid" is also incorrect. While some states require advance directives to be notarized or witnessed, not all states do. It is important for the client to check with their state's laws regarding advance directives to ensure that their document is legally binding.

d. "My partner needs to be present when I sign this document" is not necessarily true. While it is recommended for the client to have a witness present when signing their advance directive, it does not have to be their partner. The witness should be someone who is not a family member, healthcare provider, or beneficiary of the client's estate.

A. Hypoglycemia B. Palpitations C. Daytime drowsiness D. Muscle pain

Correct Answer is D

Explanation

d. Muscle pain.

Atorvastatin is a medication used to lower cholesterol levels in the blood. One of the potential adverse eﬀects of atorvastatin is myopathy, a condition characterized by muscle pain, weakness, and tenderness. In severe cases, myopathy can progress to rhabdomyolysis, a potentially life-threatening condition in which muscle breakdown products are released into the bloodstream and can cause kidney damage.

Therefore, the nurse should instruct the client to monitor for muscle pain, weakness, or tenderness and report these symptoms to the healthcare provider immediately. Hypoglycemia, palpitations, and daytime drowsiness are not commonly associated with atorvastatin use and would not require immediate reporting to the healthcare provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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