A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

Cool skin

Numbness

Edema

Pallor

Answer and Explanation

The Correct Answer is C

A. Cool skin: Cool skin is not typically associated with thrombophlebitis. It is more common with arterial issues rather than venous problems.

B. Numbness: Numbness is generally a sign of nerve involvement or arterial occlusion, not a classic finding of thrombophlebitis, which primarily affects veins.

C. Edema: Edema is a common finding with thrombophlebitis due to venous inflammation and obstruction of blood flow, which leads to fluid accumulation in the affected limb.

D. Pallor: Pallor is more commonly associated with arterial insufficiency rather than venous issues like thrombophlebitis. Thrombophlebitis often presents with redness and warmth instead of pallor.

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Correct Answer is C

Explanation

A. Eggs: Eggs, particularly the yolks, are high in cholesterol and should be limited in a low-cholesterol diet.

B. Milk: Full-fat milk is high in saturated fat and cholesterol. If the client consumes milk, it should be low-fat or non-fat varieties.

C. Beans: Beans are high in fiber and low in fat and cholesterol. They are an excellent choice for a low-cholesterol diet.

D. Liver: Liver is high in cholesterol and should be avoided by clients following a low-cholesterol diet.

A. Tell the client to take another nitroglycerin tablet in 15 min. B. Advise the client to take an antacid. C. Advise the client to come into the office. D. Instruct the client to call 911.

Correct Answer is D

Explanation

A. Tell the client to take another nitroglycerin tablet in 15 minutes. Nitroglycerin can be taken every 5 minutes, up to three doses, for chest pain. Waiting 15 minutes to take another dose is too long and can delay necessary treatment.

B. Advise the client to take an antacid. Antacids are not appropriate for managing chest pain that may be related to angina or a myocardial infarction. This response may delay critical treatment.

C. Advise the client to come into the office. This would delay care in a potential emergency situation. If the client is experiencing unrelieved chest pain after taking nitroglycerin, immediate emergency care is necessary.

D. Instruct the client to call 911. Chest pain unrelieved by nitroglycerin is a sign of a possible myocardial infarction, which is a medical emergency. The client should call 911 immediately to receive urgent care.

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A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

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Naxlex Comprehensive Predictor Exams

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