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 C

Explanation

The correct answer is: C.

Choice A reason: A pH of 7.50 and HCO3 of 31 mm Hg suggest a metabolic alkalosis due to the high bicarbonate level. However, during a panic attack, hyperventilation leads to respiratory alkalosis, not metabolic, due to the excessive exhalation of CO2, which is not consistent with this option.

Choice B reason: A pH of 7.30 and HCO3 of 19 mm Hg indicate a metabolic acidosis due to the low bicarbonate level. This is not typically associated with hyperventilation during a panic attack, which usually causes respiratory alkalosis, characterized by a decrease in CO2 levels and an increase in pH.

Choice C reason: A pH of 7.47 and PaCO2 of 31 mm Hg are indicative of respiratory alkalosis, which is expected during hyperventilation as a result of a panic attack. Hyperventilation causes a decrease in carbon dioxide (PaCO2) levels, leading to an increase in pH. The normal ranges for arterial blood gases are: pH 7.35-7.45, PaCO2 35-45 mm Hg, and HCO3 22-26 mEq/L.

Choice D reason: A pH of 7.32 and PaCO2 of 50 mm Hg suggest respiratory acidosis due to the elevated PaCO2 level. This would be more consistent with hypoventilation, which is not the case during a panic attack where hyperventilation occurs.

A. "A headache indicates tolerance to the medication.”. B. "It sounds as if you are allergic to this medication.”. C. "A headache is a common adverse effect of this medication, but it will probably occur less often over time.”. D. "Your headache is probably a result of anxiety about the chest pain.”.

Correct Answer is C

Explanation

Choice A rationale:

Tolerance to nitroglycerin is not indicated by the presence of a headache. Nitroglycerin is a vasodilator used to relieve angina, and headaches can be a common side effect.

Choice B rationale:

Allergic reactions to nitroglycerin are rare, and a headache is not a typical symptom of an allergy to this medication.

Choice C rationale:

"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”. This is the correct response. Nitroglycerin commonly causes headaches due to its vasodilatory effects. Patients often experience this side effect initially, but it tends to improve or occur less frequently with continued use. The nurse should educate the client about this and reassure them that the headaches should diminish over time.

Choice D rationale:

Anxiety may exacerbate chest pain, but it is not the likely cause of the headache. It is important to address the headache as a potential side effect of the medication.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

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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?