A client has been taking aspirin 325 mg six to eight times a day for the past two weeks to control pain from a knee injury.
Which symptom reported by the client should the nurse report to the health care provider (HCP) for priority follow-up?
Tarry-colored stools.
Swelling of the leg and knee.
Right upper quadrant discomfort.
Bruising around the injured knee.
The Correct Answer is A
This is because aspirin can cause gastrointestinal bleeding, ulceration, and perforation as side effects. Tarry-colored stools indicate the presence of blood in the stool, which is a sign of bleeding in the upper gastrointestinal tract.
This is a serious condition that requires immediate medical attention.
Choice B. Swelling of the leg and knee is wrong because it is not related to aspirin use.
It may indicate inflammation, infection, or injury of the leg and knee, but it is not a priority symptom to report to the HCP.
Choice C. Right upper quadrant discomfort is wrong because it is not related to aspirin use.
It may indicate liver or gallbladder problems, but it is not a priority symptom to report to the HCP.
Choice D. Bruising around the injured knee is wrong because it is not related to aspirin use.
It may indicate trauma, bleeding disorders, or coagulation problems, but it is not a priority symptom to report to the HCP.
Normal ranges for bleeding time are 2 to 7 minutes. Normal ranges for PTT are 25 to 35 seconds. Normal ranges for liver enzymes are AST 10 to 40 U/L and ALT 7 to 56 U/L.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the appropriate action because it prevents the spread of infection and maintains a clean environment.
The nurse should also wear gloves and dispose of the bag properly.
Choice A is wrong because saturating the dressing with saline before removing it can cause maceration of the skin and increase the risk of infection. The dressing should be removed gently and carefully, and if it is adhered to the wound, small amounts of sterile saline can be used to loosen it.
Choice C is wrong because using the old dressing to debride any tissue that is adhered to the wound can cause trauma, bleeding, and pain. The nurse should use sterile forceps or cotton- tipped applicators to gently press moistened gauze into the wound surfaces.
Choice D is wrong because reinserting the drain if removed with the dressing can cause injury and infection. The nurse should notify the surgeon immediately if the drain is accidentally removed.
Correct Answer is D
Explanation
The needle gauge size for subcutaneous injections should be between 25 and 31, depending on the patient’s size and the viscosity of the medication.
A smaller gauge number means a larger diameter needle, which can cause more pain and tissue damage.
Choice A is wrong because 8 is too large for subcutaneous injections and can cause bleeding and bruising.
Choice B is wrong because 20 is also too large for subcutaneous injections and can cause similar complications as choice A.
Choice C is wrong because 21 is still too large for subcutaneous injections and can cause discomfort and injury to the patient.
The needle length for subcutaneous injections should be between ½ inch and ⅝ inch, depending on the amount of subcutaneous tissue present. The nurse should pinch the skin and insert the needle at a 45-degree angle to ensure proper delivery of the medication.
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