A nurse is caring for a client on day 2 following a total hip replacement. The client is on bedrest except for physical therapy, and is receiving enoxaparin and intermittent pneumatic compression (IPC) devices. During assessment, the nurse notes the following:
• Left calf is firm and tender to the touch
• Mild swelling in the left lower leg compared to the right
• No redness or bruising
• Vital signs: T 98.6°F, HR 92, BP 130/84 mm Hg, RR 20, O₂ sat 97% on room air
Which action should the nurse take first?
Administer prescribed pain medication for discomfort
Elevate the left leg and apply compression
Encourage the client to ambulate to improve circulation
Notify the healthcare provider
The Correct Answer is D
Choice A reason: Administering pain medication may provide comfort, but it does not address the potential underlying cause—possible deep vein thrombosis (DVT).
Choice B reason: Elevating and compressing the leg may worsen a suspected DVT by dislodging the clot, increasing the risk of pulmonary embolism.
Choice C reason: Encouraging ambulation in the presence of a suspected DVT is contraindicated due to the risk of clot migration.
Choice D reason: The presence of calf tenderness, swelling, and firmness are classic signs of DVT. Immediate notification of the healthcare provider is essential for diagnostic evaluation and treatment initiation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While diminished deep tendon reflexes can occur with hypomagnesemia, they are not the most critical or immediate concern.
Choice B reason: Magnesium plays a vital role in cardiac conduction. Low magnesium levels can lead to ECG changes such as prolonged QT interval, ventricular arrhythmias, and torsades de pointes. This makes ECG monitoring a priority.
Choice C reason: Hyperactive bowel sounds may be present in Crohn’s disease but are not directly linked to magnesium deficiency.
Choice D reason: Chvostek's and Trousseau's signs are more specific to hypocalcemia, not hypomagnesemia, although magnesium deficiency can sometimes mimic these signs.
Correct Answer is C
Explanation
Choice A reason: Fatigue and changes in consciousness are not typical adverse effects of inhaled fluticasone. These symptoms may indicate systemic corticosteroid toxicity but are not common with inhaled formulations at therapeutic doses.
Choice B reason: Dyspnea and increased secretions are more likely related to asthma exacerbations or infections, not directly caused by fluticasone. Inhaled corticosteroids aim to reduce inflammation and secretions.
Choice C reason: Cough and oral thrush are well-documented adverse effects of inhaled fluticasone. Thrush results from fungal overgrowth due to local immunosuppression in the oropharynx. Rinsing the mouth after use helps prevent this.
Choice D reason: Increased appetite and weight gain are more associated with systemic corticosteroids. Inhaled fluticasone has minimal systemic absorption when used correctly.
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