An adult female client, who is an office worker, comes to the occupational health dinic with an edematous right leg twice the size of the left leg. The client reports that she is otherwise healthy, smokes 2 packs of cigarettes a day, and takes birth control pills on a regular basis. Which initial nursing action should the occupational health nurse take?

Ask the client to rate her pain on a scale from 0 to 10.

Teach the client to keep the leg elevated

Treat with ice then apply an elastic bandage wrap.

Check the leg for warmth and erythema.

Answer and Explanation

The Correct Answer is D

A.   While pain assessment is important, it's not the priority in this situation. Pain can be present in various conditions, and it doesn't necessarily indicate DVT.
B.   Elevating the leg can help reduce swelling but is not the initial action. The nurse needs to rule out a serious condition like DVT first.
C.   Applying ice and an elastic bandage might be appropriate for some types of swelling but is not the correct initial action for a sudden, unilateral leg swelling.
D.   The client presents with sudden, unilateral leg swelling, which is a red flag for deep vein thrombosis (DVT). DVT is a serious condition that can lead to pulmonary embolism. Therefore, the nurse's priority is to assess for signs of inflammation, which are warmth and erythema.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. The sudden onset of flashing lights and floaters can be a symptom of a detached retina, a serious eye condition that requires immediate medical attention.
B. This is incorrect. The client should not engage in any activities until the condition is evaluated by a healthcare professional.
C. While rest might seem appropriate, the client should seek immediate medical attention due to the potential seriousness of the symptoms.
D. Warm compresses are not indicated for this condition, and the client should seek immediate medical attention.

A. Place an indwelling urinary catheter and attach a bedside drainage unit. B. Send the client to x-ray for a flat plate of the abdomen. C. Insert a nasogastric tube (NGT) and attach to low intermittent suction. D. Give a prescribed analgesic for temperature above 101° F (38.3°C).

Correct Answer is C

Explanation

A. An indwelling urinary catheter is generally used for monitoring urine output in patients with urinary issues or those who are unable to void. It is not the first-line intervention for a client with symptoms suggesting a possible bowel obstruction or gastrointestinal complication. While monitoring urine output may be important, it does not address the immediate concern of the client’s gastrointestinal symptoms.
B. An abdominal x-ray can help diagnose conditions such as bowel obstruction, ileus, or other abdominal issues by visualizing the presence of air-fluid levels or distended bowel loops. While this diagnostic step is important, it should follow interventions that might provide immediate symptomatic relief or help manage the suspected condition.
C. Inserting an NGT and attaching it to low intermittent suction is a critical intervention for managing symptoms of bowel obstruction or severe gastrointestinal distress. The dark brown, foul-smelling vomit and hyperactive bowel sounds suggest that the client might have a bowel obstruction or significant gastrointestinal complication. An NGT can help decompress the stomach, relieve pressure, reduce vomiting, and prevent further gastrointestinal complications.
D. While providing analgesics for pain and fever is important for overall symptom management, it does not address the immediate cause of the client’s symptoms. The focus should be on diagnosing and managing the underlying issue causing the symptoms, such as a bowel obstruction, rather than just treating pain or fever.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?

Exhibits The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding. Each row must have one option selected.

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?