A client activated the call light to inform the nurse of sudden onset of lower leg pain. On assessment, the left leg is visibly swollen and reddened. Which action by the nurse is most appropriate?
Elevate the leg to temporarily restore venous return
Massage the leg to dislodge any thrombi
Notify the provider that the client has signs and symptoms of venous thromboembolism (VTE)
Administer PRN subcutaneous heparin
The Correct Answer is C
Choice A reason: Elevating the leg may help with venous return but is not the priority when signs of VTE are present. Immediate medical evaluation is required.
Choice B reason: Massaging a leg with suspected thrombus is contraindicated. It may dislodge the clot and lead to pulmonary embolism.
Choice C reason: Sudden pain, swelling, and redness are hallmark signs of VTE. Prompt provider notification is essential to initiate diagnostic testing and treatment.
Choice D reason: Administering anticoagulants without a confirmed diagnosis or provider order is inappropriate and potentially unsafe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While separating fluid intake from meals may reduce gastric distension, it is not a primary recommendation for hiatal hernia management.
Choice B reason: Elevating the head of the bed helps reduce nighttime reflux by preventing gastric contents from moving upward into the esophagus. This is a well-supported intervention for hiatal hernia-related GERD.
Choice C reason: Avoiding reclining after meals is helpful, but the recommended duration is typically at least 2–3 hours, not just 30 minutes.
Choice D reason: Antacids may provide temporary relief, but they are not a preventive strategy and should not be taken routinely before meals without provider guidance.
Correct Answer is D
Explanation
Choice A reason: Ambulating to the bathroom is not an alarming sign and may indicate the client is stable enough to perform basic activities.
Choice B reason: A weight gain of 2 lbs may suggest fluid retention but is not immediately life-threatening. It warrants monitoring but not urgent intervention.
Choice C reason: Bilateral pitting edema is a common symptom of CHF and indicates fluid overload, but it is not necessarily emergent unless rapidly worsening.
Choice D reason: New onset of confusion and restlessness may indicate hypoxia, cerebral hypoperfusion, or worsening heart failure. These are red flag symptoms requiring immediate evaluation and intervention.
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