The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?
Fat emboli.
Deep vein thrombosis.
Infection.
Pulmonary embolism.
The Correct Answer is B
Choice A reason: Fat emboli are typically associated with long bone fractures and not commonly linked with dehydration or immobility.
Choice B reason: Deep vein thrombosis (DVT) is a common condition in immobile patients, and redness and swelling in the calf are classic signs.
Choice C reason: While infection can cause redness and swelling, it is usually accompanied by other signs such as fever, which is not mentioned here.
Choice D reason: Pulmonary embolism is a complication that can arise from DVT but would not be the direct cause of calf redness and swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While pneumatic compression devices are used for DVT prevention, they are not the immediate intervention for suspected stroke.
Choice B reason: Placing an indwelling urinary catheter is not the first-line intervention for a patient with suspected stroke symptoms.
Choice C reason: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.
Choice D reason: Aspirin may be used in the management of stroke, but only after a stroke has been confirmed and not as an immediate intervention.
Correct Answer is C
Explanation
Choice A reason: Applying a water-soluble lubricant to the catheter is not recommended during tracheostomy suctioning as it may introduce contaminants.
Choice B reason: Instilling sodium chloride before suctioning is not a standard practice and can lead to complications such as edema.
Choice C reason: Wearing protective goggles is important to protect the nurse from potential splashes of bodily fluids during the suctioning process.
Choice D reason: Instructing the client to cough as the suction tip is removed is not recommended as it can cause discomfort and potential harm to the tracheal lining.
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