A nurse is planning care for a group of clients on a medical-surgical unit.
Which of the following actions should the nurse take first?

Collecting data from a client who reports unilateral calf pain when ambulating.

Taking a telephone prescription for a client who is to be transferred from PACU.

Reassuring the partner of a client who sustained a closed head injury.

Reinforcing a client's dressing on an above-the-knee amputation surgical site.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should prioritize collecting data from a client who reports unilateral calf pain when ambulating. This symptom could indicate the presence of a deep vein thrombosis (DVT), a potentially life-threatening condition. DVT occurs when a blood clot forms in a deep vein, often in the lower extremities. If left untreated, the clot can dislodge and travel to the lungs, causing a pulmonary embolism. Immediate assessment is crucial to rule out DVT and provide appropriate interventions. The nurse should assess the client's calf for swelling, redness, warmth, and tenderness and may also order diagnostic tests like a duplex ultrasound.

Choice B rationale:

Taking a telephone prescription for a client being transferred from the PACU is important but not the top priority in this situation. While timely transfer and adequate post-operative care are essential, addressing a client with unilateral calf pain and the potential for a DVT takes precedence due to the risk of a life-threatening complication.

Choice C rationale:

Reassuring the partner of a client who sustained a closed head injury is a compassionate action but should not be the first priority. The partner's emotional support can be provided once the immediate medical concerns have been addressed.

Choice D rationale:

Reinforcing a client's dressing on an above-the-knee amputation surgical site is important for the client's post-operative care, but it is not the highest priority when compared to the possibility of a DVT. The nurse should address the client's calf pain first and then attend to the dressing reinforcement.

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

Explanation

Choice A rationale:

Dyspnea is a common finding in clients with emphysema. Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of the alveoli in the lungs, leading to difficulty breathing and shortness of breath. The loss of alveoli reduces the surface area for gas exchange, causing dyspnea.

Choice B rationale:

Bradycardia is not typically associated with emphysema. In fact, it is more common for clients with emphysema to have an increased heart rate (tachycardia) due to the body's compensatory response to low oxygen levels in the blood.

Choice C rationale:

Clubbing of the fingers is often seen in clients with chronic respiratory conditions like emphysema. It is a result of chronic hypoxia and is characterized by the abnormal rounding and thickening of the fingertips and nail beds.

Choice D rationale:

Barrel chest is a common physical finding in clients with emphysema. It is characterized by an increase in the anteroposterior diameter of the chest due to overinflation of the lungs. This change in chest shape is a result of chronic air trapping and hyperinflation, which are hallmarks of emphysema.

Choice E rationale:

Shallow respirations are expected in clients with emphysema. Due to the loss of alveolar elasticity and increased airway resistance, clients with emphysema tend to take shallow breaths, which are less effective for oxygen exchange.

A. "I will drink about 34 ounces of fluid every day.”. B. "I will inhale slowly through pursed lips to help me breathe better.”. C. "I will follow a diet high in calories and protein.”. D. "I will lie on my stomach to practice abdominal breathing every day.”. .

Correct Answer is C

Explanation

The correct answer is choice C: “I will follow a diet high in calories and protein.”

Here are the rationales for each choice:

Choice A rationale:“I will drink about 34 ounces of fluid every day.” While staying hydrated is important for overall health, this statement does not specifically address a key self-management strategy for emphysema. Adequate fluid intake can help thin mucus, making it easier to expel, but it is not the most critical aspect of managing emphysema.

Choice B rationale:“I will inhale slowly through pursed lips to help me breathe better.” This statement is incorrect because the correct technique is toexhalethrough pursed lips, not inhale. Pursed-lip breathing helps to keep the airways open longer, reduce shortness of breath, and improve the exchange of oxygen and carbon dioxide.

Choice C rationale:“I will follow a diet high in calories and protein.” This is the correct answer. Emphysema can increase the body’s energy expenditure due to the effort required for breathing. A diet high in calories and protein helps maintain muscle mass and provides the necessary energy to support respiratory function.

Choice D rationale:“I will lie on my stomach to practice abdominal breathing every day.” This statement is not recommended for emphysema management. While abdominal or diaphragmatic breathing can be beneficial, lying on the stomach is not a typical position for practicing this technique. It is usually done while sitting or lying on the back.

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A nurse is planning care for a group of clients on a medical-surgical unit.Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has emphysema.Which of the following findings should the nurse expect? (Select all that apply.).

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

Explanation

A nurse is reinforcing teaching about self-management strategies with a client who has emphysema. Which of the following client statements indicates that the client understands the instructions?

Correct Answer is C

Explanation

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A nurse is planning care for a group of clients on a medical-surgical unit.
Which of the following actions should the nurse take first?