A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
A client who had a renal biopsy 3 hr ago and has pink-tinged urine
A client who has a femur fracture and reports numbness of the toes
A client who has cirrhosis and severe pruritus
A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge
The Correct Answer is B
Numbness of the toes in a client with a femur fracture may indicate neurovascular compromise, which requires immediate attention.
It could be a sign of impaired circulation or nerve damage, and prompt assessment is needed to prevent further complications or permanent damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Pain in the calf can be a potential symptom of deep vein thrombosis (DVT), which is a serious complication after surgery. Monitoring the client's pulse oximetry can help assess for signs of decreased oxygenation, which may indicate a possible clot or compromised circulation. A decrease in oxygen saturation can be an early indicator of a potential DVT-related complication, such as a pulmonary embolism. Monitoring the pulse oximetry can provide valuable information for timely intervention and management.
Instructing the client to massage the calf gently is not advisable without further assessment and evaluation. Massaging the calf can potentially dislodge a clot if one is present, leading to further complications. It is important to rule out DVT through appropriate diagnostic measures before providing specific instructions for calf massage.
Maintaining the leg in a dependent position while in bed can potentially worsen the symptoms and increase the risk of venous stasis. Elevating the affected leg, rather than maintaining it in a dependent position, can help improve venous return and reduce pain or swelling.
Applying a cold compress to the client's calf is not recommended without further assessment. Heat or cold therapy should be applied based on the underlying cause of the pain. In the case of potential DVT, applying a cold compress can increase vasoconstriction and potentially worsen the condition. It is essential to investigate the cause of the pain first and consult with the healthcare provider before initiating any specific therapies or interventions.
Correct Answer is D
Explanation
Hyperactive bowel sounds refer to an increased intensity, frequency, and loudness of bowel sounds. They are typically described as loud, high-pitched, and occurring more frequently than normal. This can indicate increased bowel motility and may be associated with conditions such as diarrhea, gastroenteritis, or bowel obstruction.
No sounds heard after listening for 3 to 5 minutes: This describes absent or hypoactive bowel sounds, where no sounds or very few sounds are heard. It can indicate decreased or absent bowel motility and may be seen in conditions such as ileus or peritonitis.
Sounds are soft and at a rate of 1/min: This describes normal or hypoactive bowel sounds, where the sounds are relatively quiet and occur at a slower rate (usually 5-34 sounds per minute). It may be observed in situations such as during sleep, after eating, or in certain conditions like constipation or paralytic ileus.
Indicates decreased motility: This is an inaccurate statement for hyperactive bowel sounds.
Hyperactive bowel sounds actually indicate increased motility, as mentioned earlier. Decreased motility would be associated with hypoactive or absent bowel sounds.
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