The triage nurse in the emergency department is assessing a client who reports pain and swelling in the right lower leg. The client's pain became much worse last night and appeared along with fever, chills, and sweating. The client states, "I hit my leg on the car door 4 or 5 days ago, and the sore is getting bigger" The client has a history of diabetes mellitus type 2. Which condition should the nurse anticipate for this client?

Venous thromboembolism (VTE)

Cellulitis

Arterial insufficiency

Thrombocytopenia

Answer and Explanation

The Correct Answer is B

A. Venous thromboembolism (VTE) - While VTE can cause leg pain and swelling, the presence of fever, chills, and localized trauma history in this scenario points more toward cellulitis.

B. Cellulitis
The client's symptoms, including pain, swelling, fever, chills, and sweating, are indicative of cellulitis, which is a bacterial skin infection. The history of trauma to the leg (hitting the leg on the car door) could have introduced bacteria into the skin, leading to the infection. The client's diabetes mellitus type 2 also increases the risk of developing skin infections due to impaired immune function and circulation. Cellulitis often presents with localized pain, swelling, warmth, redness, and systemic symptoms like fever and chills. Immediate medical evaluation and appropriate antibiotic treatment are necessary for cellulitis.

C. Arterial insufficiency - Arterial insufficiency typically presents with symptoms like intermittent claudication, rest pain, and non-healing wounds due to poor circulation. The symptoms described in the scenario are more consistent with an acute infection (cellulitis) rather than chronic arterial insufficiency.

D. Thrombocytopenia - Thrombocytopenia is a condition characterized by low platelet count and does not directly cause localized pain, swelling, and redness in the leg as described in the scenario.

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Correct Answer is ["25"]

Explanation

To calculate the number of hours required to infuse two 1L bags of normal saline at a rate of 80 ml/hr, you can use the following formula:

Time (hours) = Total volume (ml) / Infusion rate (ml/hr)

First, calculate the total volume of normal saline to be infused:

Total volume = 2 bags x 1L/bag x 1000 ml/L = 2000 ml

Now, plug this into the formula:

Time (hours) = 2000 ml / 80 ml/hr

Time (hours) = 25 hours

So, it will take 25 hours to infuse the total amount of normal saline at a rate of 80 ml/hr, assuming no interruptions in the infusion. Rounded to the nearest whole number, it will take 25 hours.

Correct Answer is ["500"]

Explanation

To calculate the infusion rate in ml/hr for a 500 ml bolus to be administered over 1 hour, you can simply set the pump to deliver the entire volume in the specified time:

500 ml / 1 hour = 500 ml/hr

So, the pump should be set at 500 ml/hr to administer the 500 ml bolus over 1 hour.

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Naxlex Comprehensive Predictor Exams

A nurse is to infuse two 1L bags of normal saline to a patient at 80ml/hr. How many hours will it take to infuse the total amount of normal saline? (Round to the whole number. Assume no interruptions in the infusion.)

Correct Answer is ["25"]

Explanation

A nurse is to administer a 500ml bolus of normal saline to a patient over 1 hour?

Correct Answer is ["500"]

Explanation

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