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 B
Explanation
Choice A rationale:
Limiting fluid intake throughout the day is not a suitable instruction for a client diagnosed with emphysema. Emphysema is a chronic obstructive pulmonary disease (COPD), and adequate hydration is important for individuals with this condition. Dehydration can lead to thicker mucus in the airways, making it harder to breathe. Clients with emphysema should be encouraged to maintain proper hydration.
Choice B rationale:
Instructing the client to breathe in through her nose and out through pursed lips is a beneficial technique for improving gas exchange in emphysema. This breathing technique, known as pursed-lip breathing, helps slow down the exhalation and maintains positive pressure in the airways, which can prevent airway collapse. It also promotes better oxygen exchange and reduces the feeling of breathlessness.
Choice C rationale:
Consuming a low-protein diet is not advisable for a client with emphysema. Protein is essential for tissue repair and overall health. Clients with emphysema should follow a balanced diet to maintain their energy levels and support their respiratory function. Restricting protein intake is not a standard recommendation for managing emphysema.
Choice D rationale:
Instructing the client to rest in a supine position is not a suitable recommendation. Emphysema clients often find it easier to breathe when in an upright or semi-Fowler's position, as it allows for better lung expansion and oxygen exchange. Resting in a supine position can compromise their ability to breathe effectively and may worsen their symptoms.
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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