A nurse is assisting in the care of a client.
Nurses' Notes Day 1 0800:
Client is alert and oriented
Breath sounds are clear and present throughout. Denies tobacco use.
Client lives in a 20-year-old, one-story house with their partner. Client reports they just returned from an 8-hr car trip. Client eats a high fiber diet and drinks 2,000 mL of
fluid/day.
Day 1,1000:
2.5 cm x 2.5 cm (1 in x 1 in) reddened area noted on client's left calf.
Calf circumference:
Left: 40 cm (15.8 in)
Right: 38.1 cm (15 in)
Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing:
lead poisoning
pneumonia
atherosclerosis
constipation
pulmonary embolism
The Correct Answer is B
The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The first priority in any emergency situation is to ensure personal safety. The nurse should immediately walk to a safe area, away from the smoke and potential danger,
before taking further action.
B. While closing doors can help contain smoke and fire, personal safety takes
precedence. The nurse should prioritize evacuating to a safe location before attempting to close doors.
C. Wrapping clients in blankets may not be appropriate in this situation, as it does not address the immediate threat posed by the smoke and potential fire. Ensuring personal safety is the priority.
D. While staying close to the ground can reduce exposure to smoke and toxic fumes in some situations, it is not the first action to take. Evacuating to a safe area is the most
important step to protect oneself from harm.
Correct Answer is B
Explanation
The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.
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