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 D

Explanation

Choice A rationale:

Facial flushing. Facial flushing is not typically associated with atelectasis. Atelectasis is the collapse of a portion of the lung, which can lead to decreased oxygenation and respiratory distress but does not directly cause facial flushing. Flushing may be related to other factors such as fever or allergic reactions.

Choice B rationale:

Dry cough. A dry cough can be a common symptom of atelectasis. As the lung tissue collapses and airways become obstructed, it can lead to irritation and a dry, non-productive cough as the body attempts to clear the airway. So, a dry cough is an expected finding in a client with atelectasis.

Choice C rationale:

Decreasing respiratory rate. A decreasing respiratory rate is not typically associated with atelectasis. In fact, atelectasis often leads to an increased respiratory rate as the body tries to compensate for the reduced oxygen exchange. The patient may experience tachypnea (rapid breathing) as a result.

Choice D rationale:

Increasing dyspnea. Increasing dyspnea is a common and expected finding in a client with atelectasis. As lung tissue collapses and oxygen exchange is compromised, the patient will likely experience worsening shortness of breath. This is a concerning symptom and should be closely monitored, as it may indicate a need for intervention to improve lung expansion and oxygenation.

A. "I'll skip my coffee the morning of my test.”. B. "I'll get 8 hours of sleep the night before the test.”. C. "I will not smoke prior to my test.”. D. "I will expect to feel chest pain during this test.”.

Correct Answer is D

Explanation

Choice A rationale:

Skipping coffee on the morning of the exercise ECG stress test is a good idea as caffeine can affect heart rate and blood pressure, but it doesn't necessarily indicate the need for further instructions.

Choice B rationale:

Getting 8 hours of sleep the night before the test is a positive choice and promotes overall well-being, but it is not a specific indicator of needing further instructions for the test.

Choice C rationale:

Not smoking before the test is an appropriate action, as smoking can also affect heart rate and blood pressure during the test. However, it does not indicate a need for further instructions.

Choice D rationale:

Expecting to feel chest pain during an exercise ECG stress test is not correct and indicates a need for further instructions. Chest pain during the test can be a sign of cardiovascular issues and should be reported immediately.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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Which of the following actions should the nurse take first?