An adult female client, who is an office worker, comes to the occupational health dinic with an edematous right leg twice the size of the left leg. The client reports that she is otherwise healthy, smokes 2 packs of cigarettes a day, and takes birth control pills on a regular basis. Which initial nursing action should the occupational health nurse take?

Ask the client to rate her pain on a scale from 0 to 10.

Teach the client to keep the leg elevated

Treat with ice then apply an elastic bandage wrap.

Check the leg for warmth and erythema.

Answer and Explanation

The Correct Answer is D

A.   While pain assessment is important, it's not the priority in this situation. Pain can be present in various conditions, and it doesn't necessarily indicate DVT.
B.   Elevating the leg can help reduce swelling but is not the initial action. The nurse needs to rule out a serious condition like DVT first.
C.   Applying ice and an elastic bandage might be appropriate for some types of swelling but is not the correct initial action for a sudden, unilateral leg swelling.
D.   The client presents with sudden, unilateral leg swelling, which is a red flag for deep vein thrombosis (DVT). DVT is a serious condition that can lead to pulmonary embolism. Therefore, the nurse's priority is to assess for signs of inflammation, which are warmth and erythema.

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Correct Answer is []

Explanation

Potential Condition
Urinary Retention
The client's symptoms, including the urge to void, feeling "wet," and the bladder scan showing 600 mL of residual urine, suggest urinary retention. Urinary retention occurs when the bladder does not empty completely or at all, leading to a buildup of urine. This can happen postoperatively due to anesthesia effects, pain, or bladder dysfunction.
Actions to Take
• Request prescription for straight catheter

A straight catheter (intermittent catheterization) is used to drain the bladder and measure the amount of urine collected. It is often preferred over an indwelling catheter in cases of acute urinary retention where temporary relief and assessment of bladder function are needed.
• Insert indwelling urinary catheter
An indwelling urinary catheter might be needed if urinary retention persists and is not relieved by other methods. It allows continuous drainage of urine and can be useful in managing acute or severe cases of urinary retention.
Parameters to Monitor
• Amount of urine output
Monitoring urine output is crucial to evaluate how effectively the bladder is emptying after catheterization or other interventions. This helps in assessing whether the urinary retention is being resolved.
• Residual urine
Checking residual urine with a bladder scanner can help determine how much urine remains in the bladder after voiding. Persistent high residual urine levels would indicate ongoing retention issues that need further intervention.

A. Assess the client's oxygen saturation level. B. Determine the client's current glucose level C. Give the client one-half cup of fruit juice. D. Give the client skim milk and crackers.

Correct Answer is B

Explanation

A. While oxygen saturation is important, it's not the priority in this situation. The client's symptoms strongly suggest hypoglycemia.
B. The client's symptoms of diaphoresis, rapid heartbeat, and shakiness are classic signs of hypoglycemia. Therefore, the first action should be to confirm this diagnosis by checking the blood glucose level.
C. Administering glucose before confirming hypoglycemia can be dangerous. If the client is hyperglycemic, giving them sugar will worsen their condition.
D. Providing food without confirming hypoglycemia is not appropriate.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?

Correct Answer is B

Explanation

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] .

A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?

When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?

Exhibits The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.

The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?