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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should identify that an effective outcome of IV fluid replacement in a client with dehydration is an increase in urine output. Urine output of 200 mL in 4 hours indicates that the kidneys are responding to the IV fluid replacement, and the client is likely rehydrating. This suggests that the renal perfusion has improved, and the client's body is eliminating waste products properly.
Choice B rationale:
A heart rate of 104 beats per minute is not necessarily indicative of the effectiveness of IV fluid replacement. Heart rate may vary for various reasons, and it is not a specific parameter for assessing the response to hydration. Other factors, such as blood pressure, should be considered to evaluate cardiovascular status.
Choice C rationale:
Peripheral pulses of +1 are not a direct indicator of the effectiveness of IV fluid replacement. While improved hydration may lead to better peripheral perfusion, this assessment is somewhat subjective and may not accurately reflect the overall effectiveness of the treatment.
Choice D rationale:
A urine specific gravity of 1.04 is not indicative of the effectiveness of IV fluid replacement. A specific gravity of 1.004 is within the normal range (normal range: 1.005-1.030) and does not necessarily indicate hydration status. It is essential to focus on urine output and other objective parameters to assess the effectiveness of hydration therapy. .
Correct Answer is B
Explanation
Choice A rationale:
Chloride 99 mEq/L. Rationale: A chloride level of 99 mEq/L is within the normal range, which is typically around 96-106 mEq/L. There is no need to report this value to the provider as it is not indicative of a significant abnormality.
Choice C rationale:
Magnesium 1.9 mg/dL. Rationale: A magnesium level of 1.9 mg/dL is within the normal range, which is generally about 1.5-2.5 mg/dL. This value is not indicative of a significant abnormality and does not require immediate reporting to the provider.
Choice D rationale:
Potassium 3.6 mEq/L. Rationale: A potassium level of 3.6 mEq/L is within the normal range, which is typically around 3.5-5.0 mEq/L. While it's on the lower side of the normal range, it is not low enough to warrant immediate reporting to the provider. However, the nurse should continue to monitor the client's potassium levels and address any potential issues if they persist or worsen.
Choice B rationale:
Sodium 126 mEq/L. Rationale: A sodium level of 126 mEq/L is below the normal range, which is typically around 135-145 mEq/L. Hyponatremia, or low sodium levels, can be a serious condition that can lead to neurological symptoms and other complications. Therefore, the nurse should promptly report this finding to the provider so that appropriate interventions can be initiated.
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