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A nurse is caring for a client who is experiencing impaired mobility.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing

and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

A. Diarrhea: Not relevant to the client's condition of impaired mobility and recent hip fracture.

B. Hypocalcemia: Not directly related to the client's current condition and symptoms.

C. Pulmonary embolism: The client is at risk due to limited mobility and signs of deep vein thrombosis.

D. Deep vein thrombosis: The client has symptoms such as a warm, reddened area on the calf, indicating a potential DVT.

E. Hypertension: The client's blood pressure is within normal limits, so this is not a primary concern.


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Related Questions

Correct Answer is A

Explanation

A. Administering pain medication is the priority action in this scenario. The patient is experiencing significant post-surgical pain, which can impair their ability to breathe deeply and effectively. Addressing pain will improve comfort and facilitate better respiratory effort.

B. Notifying the healthcare provider immediately is not warranted based on the current findings. The amount of drainage (50 mL) is within expected limits for the first hour after surgery, and fluctuation in the water seal chamber indicates the chest tube is functioning properly.

C. Repositioning the patient to the unaffected side may help with comfort but is not the most appropriate action to address the pain or improve respiratory status in this situation.

D. Documenting the findings and continuing to monitor the drain is important but does not address the patient’s immediate need for pain relief.

Correct Answer is B

Explanation

A. Checking the client’s PTT level is unnecessary in this situation because low molecular weight heparin (e.g., enoxaparin) does not typically require PTT monitoring. This test is more relevant for clients receiving unfractionated heparin.

B. Small purple hemorrhagic areas (ecchymosis) at the injection sites are a common and expected side effect of low molecular weight heparin. The nurse should explain to the client that this is a normal reaction to the medication and does not indicate a serious issue.

C. Notifying the healthcare provider immediately is not warranted unless the client shows signs of excessive bleeding, such as hematomas, significant bruising, or a drop in blood pressure. The described ecchymosis is a minor and expected side effect.

D. Assessing the client’s blood pressure and heart rate is a reasonable step if there are concerns about significant bleeding or hemodynamic instability. However, in this case, the described symptoms are localized and do not suggest systemic bleeding.

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