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 C
Explanation
School-age children typically have a growing awareness of their bodies and an understanding of potential harm or pain. They may fear procedures or treatments that involve physical discomfort, such as injections, blood draws, or invasive procedures. The fear of experiencing pain or bodily injury can cause anxiety and distress in school-age children.
It is important for the nurse to acknowledge and address the child's fear of pain or bodily injury by providing age-appropriate explanations, offering reassurance, and implementing strategies to minimize discomfort. This may involve using distraction techniques, providing emotional support, and ensuring proper pain management during procedures.
While loss of privacy and control, separation anxiety, and stranger anxiety can also be stressors for school-age children, the fear of pain or bodily injury is often a significant concern that may require specific attention and interventions from the nurse.
Correct Answer is B
Explanation
Prednisone is a corticosteroid medication that can cause a range of side effects, including fluid retention, electrolyte imbalance, and increased blood pressure. A blood pressure reading of 148/94 mm Hg indicates hypertension, which may be related to the use of prednisone. It is essential to report this finding to the health care provider as it may require further evaluation and management, such as adjusting the medication dosage or initiating additional treatments to control blood pressure. The other information provided, such as stopping the medication, ankle edema, and not taking prescribed vitamin D, is relevant but does not pose an immediate threat to the patient's health compared to uncontrolled hypertension.
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