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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Taking hydrochlorothiazide on an empty stomach is not a requirement for this medication. Hydrochlorothiazide is a diuretic used to treat conditions like hypertension and edema. It can be taken with or without food, and food may help reduce stomach upset for some individuals.

Choice B rationale:

Muscle weakness is an adverse effect of hydrochlorothiazide. Therefore, it is not an expected outcome. Hydrochlorothiazide is a thiazide diuretic, and one of its common side effects is potassium loss through increased urine output. This can lead to muscle weakness and cramping. The nurse should educate the client about the signs and symptoms of low potassium and the importance of including potassium-rich foods in their diet.

Choice C rationale:

Increasing daily intake of foods high in potassium is essential information to include in the teaching for a client taking hydrochlorothiazide. Thiazide diuretics like hydrochlorothiazide can cause potassium depletion, which may result in adverse effects like muscle weakness, cramping, and cardiac dysrhythmias. Therefore, advising the client to consume potassium-rich foods, such as bananas, oranges, and potatoes, can help counteract the potassium loss associated with the medication.

Choice D rationale:

Taking the medication at bedtime is not a specific requirement for hydrochlorothiazide. Thiazide diuretics can be taken at various times of the day, depending on the client's preferences and when they are most compliant with their medication regimen. The timing of administration should be consistent to maintain the medication's effectiveness.

A. "I will wear stockings with elastic tops.”. B. "I will avoid crossing my legs at the knees.”. C. "I will not go barefoot.”. D. "I will use a thermometer to check the temperature of my bath water.”. .

Correct Answer is A

Explanation

The correct answer is Choice A: "I will wear stockings with elastic tops."

Choice A rationale:

Wearing stockings with elastic tops can constrict blood flow in the legs, which is counterproductive for individuals with peripheral vascular disease. Compression stockings specifically designed for PVD are recommended, but these should be properly fitted and used according to medical advice.

Choice B rationale:

Avoiding crossing the legs at the knees is appropriate for individuals with PVD, as this can impede blood flow and worsen symptoms.

Choice C rationale:

Not going barefoot is important for clients with PVD, as it reduces the risk of injury and infection, which can be more serious due to compromised circulation.

Choice D rationale:

Using a thermometer to check the temperature of bath water is crucial for clients with PVD to avoid burns, since they may have decreased sensation in their extremities.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 reinforcing teaching with a client who is taking hydrochlorothiazide.Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who is scheduled for an exercise ECG stress test.Which of the following comments should indicate to the nurse that the client requires further instructions?

A nurse is measuring the vital signs of a client he suspects has hypovolemic shock.Which of the following findings should the nurse expect?

A nurse is reviewing a client's laboratory results. Which of the following findings should the nurse report to the provider?

A nurse is contributing to the plan of care for a client who has COPD.Which of the following interventions should the nurse include in the plan of care?

A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement.Which of the following findings should the nurse identify as effectiveness of the treatment?

A nurse is caring for a client who has asthma. The client asks the nurse how albuterol helps his breathing. Which of the following information should the nurse include in the response? (Select all that apply.).

A nurse reviewing the laboratory of a client who had a total thyroidectomy discovers that his calcium level is 7 mg/dL. Which of the following client findings should the nurse expect?

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?