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 B
Explanation
Choice A rationale
While Vitamin B is important for overall health, it is not specifically known to promote wound healing.
Choice B rationale
Protein is essential for wound healing. It helps to repair body tissues and is vital for skin repair and immunity. Inadequate protein intake can impair collagen formation and slow down the wound healing process.
Choice C rationale
While calcium is important for bone health, it is not specifically known to promote wound healing.
Choice D rationale
Vitamin D helps the body absorb calcium, but it is not specifically known to promote wound healing.
Correct Answer is B
Explanation
Choice A rationale
Auscultation of a bruit over the pedal pulse is not a typical symptom of DVT. A bruit is a sound heard over an artery due to turbulent blood flow. While it may indicate vascular disease, it is not a symptom of DVT121314.
Choice B rationale
Groin tenderness can be a symptom of DVT. DVT often causes pain or tenderness in the affected area, which can include the groin.
Choice C rationale
Pallor in the affected extremity is not a typical symptom of DVT. DVT can cause swelling and warmth in the affected area, but it does not typically cause pallor.
Choice D rationale
Cramping pain in one foot is not a typical symptom of DVT. DVT often causes pain or swelling in the affected leg, but the pain is not typically limited to the foot.
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