A client on bedrest complains of pain and burning in the right calf area. What is the nurse's next action?
Deeply palpate the area for rebound tenderness
Percuss over the area for a change in tone
Compare the circumference to the left calf
Medicate the client for pain and reassess in 60 minutes
The Correct Answer is C
Choice A reason: Deeply palpating the area for rebound tenderness is not the nurse's next action, because it is inappropriate and dangerous. Deeply palpating the area for rebound tenderness is a test that involves applying and releasing pressure on the abdomen, which can elicit pain or discomfort in the presence of peritonitis or appendicitis. Deeply palpating the area for rebound tenderness is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Deeply palpating the area for rebound tenderness can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.
Choice B reason: Percussing over the area for a change in tone is not the nurse's next action, because it is inappropriate and useless. Percussing over the area for a change in tone is a test that involves tapping on the chest or abdomen, which can produce different sounds depending on the density of the underlying organs or tissues. Percussing over the area for a change in tone is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Percussing over the area for a change in tone can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.
Choice C reason: Comparing the circumference to the left calf is the nurse's next action, because it is appropriate and useful. Comparing the circumference to the left calf is a test that involves measuring the size of the leg, which can reveal any swelling or edema in the affected area. Comparing the circumference to the left calf is relevant and useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Comparing the circumference to the left calf can also help diagnose, monitor, or treat the condition, as a difference of more than 2 cm between the legs can suggest a DVT.
Choice D reason: Medicating the client for pain and reassessing in 60 minutes is not the nurse's next action, because it is inappropriate and delayed. Medicating the client for pain and reassessing in 60 minutes is an intervention that involves giving the client a painkiller and checking the response after an hour. Medicating the client for pain and reassessing in 60 minutes is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Medicating the client for pain and reassessing in 60 minutes can also mask the symptoms, delay the diagnosis, or miss the opportunity to prevent the complications, such as pulmonary embolism, which is a lifethreatening condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Flushing the exposed skin with water is the first action that the nurse should take if they are stuck by a needle. This is to reduce the amount of blood or body fluid that may have entered the wound and to prevent infection. The nurse should flush the skin for at least 15 minutes and avoid using soap, antiseptic, or bleach as they may damage the skin or increase the risk of infection.
Choice B reason: Reporting the exposure is the second action that the nurse should take after flushing the exposed skin with water. This is to inform the supervisor, the occupational health department, or the infection control team about the incident and to initiate the postexposure protocol. The nurse should provide the details of the exposure, such as the type and source of the needle, the depth and location of the wound, and the status of the source patient.
Choice C reason: Seeking medical attention is the third action that the nurse should take after reporting the exposure. This is to receive a medical evaluation and treatment, such as testing, prophylaxis, counseling, and followup. The nurse should consult a health care provider as soon as possible and follow the recommendations for preventing or treating any potential infections, such as hepatitis B, hepatitis C, or HIV.
Choice D reason: Completing an incident report is the last action that the nurse should take after seeking medical attention. This is to document the exposure and the actions taken and to identify the causes and the preventive measures for the future. The nurse should fill out the incident report form accurately and objectively and submit it to the appropriate authority. The incident report is not a part of the client's record and should not be mentioned in the client's chart.
Correct Answer is ["A","B"]
Explanation
Choice A reason: Polyuria is the production of abnormally large amounts of urine, which can be caused by various factors, such as diabetes, kidney disease, or diuretics. Polyuria is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not affect the urinary system directly, unless the inflammation is located in the kidneys or bladder.
Choice B reason: Edema is the swelling of tissues due to excess fluid accumulation, which can be caused by various factors, such as heart failure, liver disease, or venous insufficiency. Edema is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not cause fluid retention, but rather fluid leakage from the blood vessels into the interstitial spaces.
Choice C reason: Heat is an expected finding in a client with inflammation, which is the body's response to injury or infection. Heat is caused by the increased blood flow to the inflamed area, which brings more oxygen and nutrients to the damaged tissues. Heat also helps to kill or inhibit the growth of microorganisms that may cause infection.
Choice D reason: Erythema is an expected finding in a client with inflammation, which is the body's response to injury or infection. Erythema is the redness of the skin due to the dilation of the blood vessels in the inflamed area, which increases the blood flow and the delivery of oxygen and nutrients to the damaged tissues. Erythema also helps to signal the presence of inflammation and attract immune cells to the site.
Choice E reason: Pain is an expected finding in a client with inflammation, which is the body's response to injury or infection. Pain is caused by the stimulation of the nerve endings by chemical mediators, such as histamine, prostaglandins, and bradykinin, that are released by the inflamed tissues. Pain also helps to alert the client of the injury or infection and to limit the movement or use of the affected area.
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