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. Placing protective padding between the client and bed rails is a safety measure to prevent injury during a seizure. This action helps protect the client from head or body trauma if they hit the bed rails or any surrounding surfaces during the seizure.
B. Providing privacy is important for maintaining the client’s dignity during a seizure, but it is not the most immediate concern. The primary focus during a seizure should be on ensuring the client’s safety and monitoring the event. Privacy can be considered once the immediate safety and medical needs are addressed.
C. Observing the client's behavior during the seizure is essential for documentation and subsequent medical evaluation. It helps in identifying the type, duration, and characteristics of the seizure, which is crucial for diagnosis and treatment. However, observation alone does not address immediate safety needs or interventions required during the seizure.
D. Recording the client's level of consciousness after the seizure is important for assessing the postictal state and the extent of recovery. This information is valuable for understanding the impact of the seizure and guiding further medical care. However, during the seizure, immediate actions should focus on ensuring safety and managing the seizure itself.

A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction). B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L). C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L). D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);

Correct Answer is C

Explanation

A. This would indicate fluid volume deficit, not improvement. Increasing IV fluids should lead to a decrease in hematocrit, not an increase.
B. This is not a desired outcome for a patient with pancreatitis, as hyperglycemia is a common complication. The focus should be on maintaining stable blood glucose levels.
C. BUN is a marker of kidney function and hydration status. A decrease in BUN indicates improved renal perfusion, which is a therapeutic outcome of increasing IV fluids.
D. While a decrease in amylase is generally a good sign for pancreatitis, it is not a direct result of increasing IV fluids. Amylase levels decrease as the pancreatitis improves.

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Naxlex Comprehensive Predictor Exams

The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?

A client admitted with thyrotoxicosis is reporting a "pounding heart in the chest." Which assessment finding warrants immediate intervention by the nurse?

The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?

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?