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 B

Explanation

Choice A rationale:
Elevating the head of the bed to a 45-degree angle is important for clients with obstructive sleep apnea (OSA) to help prevent airway obstruction during sleep. However, this should not be the nurse's immediate priority before leaving the client. Ensuring the client's positive airway pressure (PAP) device is properly applied is more crucial.
Choice C rationale:
While locking the side rails in place is generally essential for safety, it is not the most critical intervention for a client with OSA and urination issues. Ensuring proper use of the PAP device is a higher priority.
Choice D rationale:
Removing dentures or other oral appliances is important for preventing airway obstruction in clients with OSA, but it should not take precedence over ensuring the use of the PAP device. The nurse should address the immediate respiratory needs of the client.

A. Discontinue the dose 2 weeks before surgery. B. Decrease the dose by half 2 weeks before surgery. C. Take the originally prescribed dose the week of surgery. D. Double the dose the week of surgery.

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.

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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

The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

Correct Answer is B

Explanation

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Correct Answer is A

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?