A nurse is caring for a client who reports an area of redness, warmth, tenderness, and pain in the right calf.

The nurse anticipates which of the following orders when notifying the provider of this finding?

Obtain impedance plethysmography.

Apply cold therapy to the affected leg.

Obtain a venous duplex ultrasound.

Monitor Homan's sign.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Impedance plethysmography is a test that uses electrical signals to measure blood flow and can be used to detect deep vein thrombosis (DVT). However, it is not the first-line diagnostic tool for DVT.
Choice B rationale:
Cold therapy can help reduce inflammation and pain, but it is not a diagnostic measure for DVT.
Choice C rationale:
Venous duplex ultrasound is the most common test used to diagnose DVT. It uses sound waves to create pictures of the blood flowing through the veins in the leg.
Choice D rationale:
Homan’s sign is a physical examination finding that was traditionally used to diagnose DVT, but it is not reliable or specific.

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Correct Answer is C,A,D,E,B

Explanation

Here’s the correct order of actions a nurse should take when infiltration is identified at an IV site: C. Stop the infusion A. Remove the IV catheter D. Apply a sterile dressing E. Elevate the extremity B. Apply warm or cold compresses ? Rationale: Stopping the infusion prevents further infiltration. Removing the catheter eliminates the source of fluid leakage. Applying a sterile dressing protects the site from infection. Elevation helps reduce swelling. Compresses (warm for older infiltrations, cold for recent ones) promote absorption and comfort.

A. Complete a neurological check. B. Increase the client's fluid intake. C. Administer the prescribed PRN antihypertensive medication. D. Hold the client's evening dose of digoxin.

Correct Answer is A

Explanation

Choice A rationale:
Completing a neurological check is the correct action. The client’s sudden confusion and drowsiness could indicate a neurological issue, such as a stroke.
Choice B rationale:
Increasing the client’s fluid intake is not the first action to take. While dehydration can cause confusion, other causes need to be ruled out first.
Choice C rationale:
Administering the prescribed PRN antihypertensive medication is not the first action to take. The client’s blood pressure is not elevated, so this medication is not needed at this time.
Choice D rationale:
Holding the client’s evening dose of digoxin is not the first action to take. The client’s symptoms are not necessarily related to this medication.

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A nurse is caring for a client who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).

Correct Answer is C,A,D,E,B

Explanation

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?

Correct Answer is A

Explanation

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A nurse is caring for a client who reports an area of redness, warmth, tenderness, and pain in the right calf.

The nurse anticipates which of the following orders when notifying the provider of this finding?