The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?
The 24-hour oral intake is 600 ml greater than the total output.
The patient's temperature is 100.3" F 137.9" C).
The patient reports abdominal pain at level 6 (0 to 10 scale) when ambulating
The patient's calf is swollen, warm, and painful.
The Correct Answer is D
These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.
DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Compartment syndrome is a condition characterized by increased pressure within a muscle compartment, leading to impaired blood flow and potential tissue damage. It can occur when swelling or bleeding within a confined space, such as a cast, causes increased pressure on the surrounding tissues.
Tingling in the toes and decreased sensation can be indicative of nerve compression or damage due to increased pressure in the compartment. It is important to recognize these neurological changes as potential signs of compartment syndrome.
Signs and symptoms of compartment syndrome may include:
- Severe pain that is out of proportion to the injury or not relieved by pain medication.
- Swelling and tightness in the affected area.
- Numbness or tingling.
- Pale or cool skin over the affected area.
- Weakness or decreased sensation in the affected limb.
- In severe cases, paralysis or loss of pulse in the affected area.
Correct Answer is C
Explanation
The client's symptoms of bounding peripheral pulses, weight gain, pitting edema, and moist crackles bilaterally suggest fluid volume overload or fluid retention. Furosemide (Lasix) is a loop diuretic that helps to promote diuresis and reduce fluid volume. Administering the medication promptly can help address the client's symptoms and alleviate the fluid overload.
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