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.

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Correct Answer is A

Explanation

A. This is the most likely intervention to avert cardiomegaly and improve myocardial contractility. By reducing blood pressure, the heart doesn't have to work as hard to pump blood, which can help prevent the heart from enlarging (cardiomegaly) and improve its ability to contract effectively.
B. While rest and oxygen can help manage symptoms of heart failure, they do not directly address the underlying issue of increased cardiac workload and hypertrophy.
C. Monitoring heart rate and rhythm is important for assessing the patient's condition, but it does not prevent cardiomegaly or improve contractility.
D. Nitroglycerin is used to treat acute symptoms of heart failure, such as chest pain, but it is not a long- term solution for preventing cardiomegaly or improving contractility.

A. Encourage active range of motion exercises. B. Assist with ambulation in the hallway. C. Provide a bedside commode for toileting. D. Teach to sleep in a side lying position.

Correct Answer is C

Explanation

A. Range of motion exercises are important for overall mobility and prevention of complications from immobility. However, they can increase cardiac workload, especially if performed actively and without supervision.
B. Ambulation, or walking in the hallway, increases cardiac workload and can exacerbate symptoms in a client with unstable angina. This activity should be minimized or restricted until the client's condition stabilizes. The focus should be on reducing activities that put additional stress on the heart.

C. Using a bedside commode helps reduce the need for the client to walk to the bathroom, which can be physically demanding and increase cardiac workload. By minimizing the effort required for toileting, the client can avoid unnecessary physical strain.
D. Sleeping in a side-lying position is not directly related to reducing cardiac workload. The client's position during sleep generally does not have as significant an impact on cardiac workload as other interventions.

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Naxlex Comprehensive Predictor Exams

A client is admitted with heart failure (HF) and left ventricular hypertrophy. Which intervention is most likely to avert development of cardiomegaly and improve myocardial contractility?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

Exhibits The nurse reviews client data. Select the 3 possible conditions that could have the clinical manifestation of clubbed nails for this client.

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?

The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to tak?

After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?

The nurse assists a client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?