A nurse is caring for a client who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?

Reports pain as 5 on a scale of 0 to 10

Been on bedrest for 3 days

Last bowel movement 2 days ago

Consumed 35% of meals for 12 hr

Answer and Explanation

The Correct Answer is B

A. "Reports pain as 5 on a scale of 0 to 10": While pain is an important concern, it is not the most immediate issue in this case. The nurse should first assess for factors that could contribute to complications or more severe issues.
B. "Been on bedrest for 3 days": Prolonged bedrest increases the risk of complications such as deep vein thrombosis (DVT), pulmonary embolism, or muscle atrophy. This is the priority because the client may be at risk for serious complications due to immobility.
C. "Last bowel movement 2 days ago": While constipation can cause discomfort, it is not as urgent as the risk posed by prolonged bedrest. This issue can be addressed once other more serious complications have been ruled out.
D. "Consumed 35% of meals for 12 hr": Poor nutrition is important to monitor, but it is not the immediate concern in this case. The focus should be on potential complications related to immobility, such as clot formation or respiratory issues.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Thoracentesis: Thoracentesis may be ordered if there is suspected pleural effusion or hemothorax following thoracic trauma. It allows for both diagnostic and therapeutic removal of fluid or blood from the pleural space and helps assess the extent of internal injury.
B. Ultrasound: Ultrasound is a non-invasive tool used to quickly assess thoracic structures such as the pleura and pericardium. It helps detect hemothorax, pneumothorax, or pericardial effusion, and is commonly used in emergency settings for rapid diagnosis.
C. Focused assessment with sonography in trauma (FAST): FAST is a rapid bedside ultrasound exam used to detect free fluid (blood) in the thoracic or abdominal cavity. In trauma cases, it helps quickly identify life-threatening internal bleeding or organ injury, making it a critical diagnostic tool.
D. Chest x-ray: A chest x-ray is a standard imaging technique used to evaluate thoracic injuries. It can reveal fractures, pneumothorax, hemothorax, and other abnormalities in the chest cavity, providing a clear view of the extent of injury.
E. Pleural cavity decompression via needle aspiration: Needle aspiration is a therapeutic procedure rather than a diagnostic tool. It is used in emergencies to relieve a tension pneumothorax, not to assess or diagnose thoracic injury. Therefore, it is not anticipated as a diagnostic measure.

A. Cyanosis B. Arrhythmias C. Asterixis D. Tachycardia

Correct Answer is C

Explanation

A. Cyanosis: Cyanosis is a late sign of hypoxemia, not specifically hypercapnia. It indicates poor oxygenation of tissues but does not directly reflect elevated carbon dioxide levels in the blood.
B. Arrhythmias: Arrhythmias may occur in respiratory failure due to hypoxemia or acid-base disturbances. However, they are not the most specific indicator of severe hypercapnia and can result from a range of metabolic or cardiac causes.
C. Asterixis: Asterixis, or "flapping tremor," is a neurologic manifestation of severe hypercapnia and altered mental status. It results from elevated CO₂ levels affecting brain function and is often seen in CO₂ narcosis or advanced respiratory failure.
D. Tachycardia: Tachycardia is a common compensatory response to hypoxia or hypercapnia, but it is nonspecific. It can be seen in many conditions and is not a definitive sign of severe carbon dioxide retention.

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A nurse is caring for a client who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who presents to the hospital with manifestations of a thoracic injury. Which of the following diagnostic tools would the nurse anticipate the health care provider to order? (Select all that apply.) (Select All that Apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is assessing a client who has respiratory failure. Which of the following manifestations should the nurse identify as indicative of severe hypercapnia?

Correct Answer is C

Explanation

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