A nurse is planning care for a group of clients on a medical-surgical unit.
Which of the following actions should the nurse take first?

Collecting data from a client who reports unilateral calf pain when ambulating.

Taking a telephone prescription for a client who is to be transferred from PACU.

Reassuring the partner of a client who sustained a closed head injury.

Reinforcing a client's dressing on an above-the-knee amputation surgical site.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should prioritize collecting data from a client who reports unilateral calf pain when ambulating. This symptom could indicate the presence of a deep vein thrombosis (DVT), a potentially life-threatening condition. DVT occurs when a blood clot forms in a deep vein, often in the lower extremities. If left untreated, the clot can dislodge and travel to the lungs, causing a pulmonary embolism. Immediate assessment is crucial to rule out DVT and provide appropriate interventions. The nurse should assess the client's calf for swelling, redness, warmth, and tenderness and may also order diagnostic tests like a duplex ultrasound.

Choice B rationale:

Taking a telephone prescription for a client being transferred from the PACU is important but not the top priority in this situation. While timely transfer and adequate post-operative care are essential, addressing a client with unilateral calf pain and the potential for a DVT takes precedence due to the risk of a life-threatening complication.

Choice C rationale:

Reassuring the partner of a client who sustained a closed head injury is a compassionate action but should not be the first priority. The partner's emotional support can be provided once the immediate medical concerns have been addressed.

Choice D rationale:

Reinforcing a client's dressing on an above-the-knee amputation surgical site is important for the client's post-operative care, but it is not the highest priority when compared to the possibility of a DVT. The nurse should address the client's calf pain first and then attend to the dressing reinforcement.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should instruct the client to discontinue the dose of acetylsalicylic acid (aspirin) 2 weeks before surgery. Aspirin is an antiplatelet medication that can increase the risk of bleeding during and after surgery. Discontinuing it before surgery helps reduce the risk of excessive bleeding during the procedure. The recommended time frame for discontinuation may vary based on the patient's surgical procedure and the surgeon's preferences. However, 2 weeks is a common guideline to ensure that the antiplatelet effects of aspirin have diminished.

Choice B rationale:

Decreasing the dose by half 2 weeks before surgery may not be sufficient to minimize the risk of bleeding associated with aspirin. It is generally recommended to discontinue the medication completely to ensure that the antiplatelet effect has worn off.

Choice C rationale:

Taking the originally prescribed dose of aspirin the week of surgery is not advisable because it can increase the risk of bleeding during the surgical procedure. It is important to discontinue aspirin well before the surgery.

Choice D rationale:

Doubling the dose of aspirin the week of surgery is contraindicated as it can significantly increase the risk of bleeding. This choice is not recommended in the context of preoperative management.

A. Fine rales. B. Rhonchi. C. Expiratory wheeze. D. Pleural friction rub.

Correct Answer is C

Explanation

Choice A rationale:

Fine rales Fine rales, also known as crackles, are typically associated with conditions like pulmonary edema, pneumonia, or interstitial lung diseases. These sounds are often described as "crackling" or "popping" and are heard during inspiration. In an acute asthma exacerbation, expiratory wheezing is more characteristic than fine rales.

Choice B rationale:

Rhonchi Rhonchi are continuous, low-pitched sounds that can be heard in conditions like chronic obstructive pulmonary disease (COPD) or bronchitis. They are typically present during both inspiration and expiration. In an acute asthma exacerbation, you would expect to hear wheezing during expiration, which is different from the characteristics of rhonchi.

Choice D rationale:

Pleural friction rub Pleural friction rub is a grating, leathery sound caused by the inflamed pleura rubbing against each other. It is typically heard during both inspiration and expiration and is associated with conditions like pleuritis or pleurisy. It is not commonly associated with acute asthma exacerbation. Now, let's move on to the next question.

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A nurse is planning care for a group of clients on a medical-surgical unit.Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a preoperative interview with a client who is scheduled for surgery.The client states that he takes acetylsalicylic acid 81 mg. by mouth daily.Prior to the client's upcoming surgery, the nurse should instruct the client to do which of the following?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is having an acute asthma exacerbation.When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

Correct Answer is C

Explanation

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A nurse is planning care for a group of clients on a medical-surgical unit.
Which of the following actions should the nurse take first?