A nurse is caring for a patient who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?
Consumed 35% of meals for 12 hr.
Been on bedrest for 3 days.
Last bowel movement 2 days ago.
Reports pain as 5 on a scale of 0 to 10.
The Correct Answer is D
Choice A rationale
While nutrition is important for recovery, consuming 35% of meals for 12 hours is not an immediate concern. The patient’s nutritional status can be addressed after more urgent issues are resolved.
Choice B rationale
Bedrest for 3 days post-surgery is not uncommon. While prolonged bedrest can lead to complications such as deep vein thrombosis, it is not the most immediate concern in this scenario.
Choice C rationale
A last bowel movement 2 days ago is not necessarily a concern unless the patient is experiencing discomfort or other symptoms of constipation. This can be addressed after more urgent issues are resolved.
Choice D rationale
This is the correct answer. Pain in the lower extremities following surgery could indicate a serious condition such as a blood clot. It is important to address this first to rule out any serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Increasing daily protein intake is often recommended for clients with chronic pancreatitis. Protein is needed for healing and repairing tissues, and people with chronic pancreatitis may have increased protein needs.
Choice B rationale
Decreasing caloric intake when abdominal pain is present is not typically recommended for clients with chronic pancreatitis. Adequate nutrition, including sufficient calories, is important for managing this condition.
Choice C rationale
Increasing fat intake when experiencing loose stools is not typically recommended for clients with chronic pancreatitis. Fat can be difficult to digest for these clients and can contribute to loose stools.
Choice D rationale
Limiting alcohol intake to 2-3 drinks per week is not typically recommended for clients with chronic pancreatitis. Alcohol can exacerbate pancreatitis and should be avoided.
Correct Answer is B
Explanation
Choice A rationale
While dietary iron restrictions can contribute to iron-deficiency anemia, they are not typically a symptom of ulcerative colitis. Ulcerative colitis is an inflammatory bowel disease that primarily affects the colon and rectum, and its symptoms are generally related to inflammation and damage in these areas.
Choice B rationale
Chronic blood loss is a common symptom of ulcerative colitis and a major contributing factor to the development of anemia in these patients. This is because the inflammation and ulceration in the colon and rectum can lead to bleeding, which over time can result in a significant loss of red blood cells.
Choice C rationale
Frequent diarrhea is a common symptom of ulcerative colitis, but it does not directly contribute to the development of anemia. However, severe or prolonged diarrhea can lead to malnutrition and malabsorption of nutrients, including iron, which could indirectly contribute to anemia.
Choice D rationale
Abdominal pain is a common symptom of ulcerative colitis, but it does not directly contribute to the development of anemia. The pain is typically caused by inflammation and ulceration in the colon and rectum, not by a loss of red blood cells.
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