An older client is hospitalized following an embolic stroke resulting in right-sided paresis. Three days after admission, the nurse notes edema and erythema to the right lower leg. These findings should alert the nurse to which possible condition?

Infection.

Deep vein thrombosis.

Pulmonary embolism.

Fat emboli.

Answer and Explanation

The Correct Answer is B

A.   Infection in the lower leg could cause localized redness, swelling, warmth, and possibly pain. However, the presence of these symptoms alone is not as specific to infection, especially without additional symptoms like fever or purulent discharge.
B.   Deep vein thrombosis is a condition where a blood clot forms in a deep vein, commonly in the legs. The symptoms of DVT include swelling (edema), redness (erythema), warmth, and sometimes pain in the affected leg. Given that the client has paresis on one side and is likely less mobile, the risk of DVT increases.
C.   A pulmonary embolism occurs when a blood clot (often from the legs) travels to the lungs and causes a blockage. While a pulmonary embolism is a serious complication of DVT, the findings of localized edema and erythema in the leg are more directly associated with DVT itself rather than the secondary complication of a pulmonary embolism.
D.   Fat emboli typically occur after fractures or trauma and lead to fat droplets entering the bloodstream and causing blockages in the lungs, brain, or skin. The classic symptoms include respiratory distress, neurological symptoms, and petechial rash.

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Correct Answer is C

Explanation

A. Revising clinical practice guidelines might be necessary in the long term if the new approach becomes widely accepted and proven effective. However, this action is typically part of a broader, organizational process that follows initial implementation and evaluation.
B. Engaging staff in evidence-based practice is crucial for successful implementation of the new approach. This involves educating and training staff on the new methods, ensuring they understand and support the change, and integrating the new practices into daily routines.
C. Evaluating the effectiveness of the change is a critical next step. After implementing a new approach, it is essential to assess whether it achieves the desired outcomes and improves client care. This evaluation involves monitoring and analyzing results to determine if the change is beneficial and meets the intended goals.
D. Consulting with a clinical nursing expert can be helpful for advice and guidance during the implementation process. However, this action is typically part of the initial planning and decision-making stages rather than the immediate next step after gathering evidence.

A. Take an over-the-counter laxative every morning. B. Drink six to eight large glasses of water daily. C. Try using over-the-counter enemas when needed. D. Walk around the block or further every day.

Correct Answer is B

Explanation

A. While over-the-counter laxatives can be effective for relieving constipation, they are typically recommended for short-term use or when dietary and lifestyle changes have not resolved the issue. Regular or frequent use of laxatives can lead to dependence and potentially worsen constipation over time.
B. Increasing water intake is a highly effective way to address constipation. Adequate hydration helps soften the stool, making it easier to pass. Drinking six to eight large glasses of water daily is a good strategy to promote regular bowel movements and prevent constipation.
C. Over-the-counter enemas can provide immediate relief from constipation but should not be used frequently. Enemas are more invasive and can cause discomfort or lead to dependency if used too often. They are typically recommended for occasional use rather than as a first-line solution for chronic constipation.
D. Regular physical activity, such as walking, can help stimulate bowel movements and alleviate constipation. Exercise promotes gut motility and can be an effective part of a comprehensive approach to managing constipation.

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An older client is hospitalized following an embolic stroke resulting in right-sided paresis. Three days after admission, the nurse notes edema and erythema to the right lower leg. These findings should alert the nurse to which possible condition?

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Naxlex Comprehensive Predictor Exams

The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. Which action should the nurse take next?

Correct Answer is C

Explanation

A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

Correct Answer is B

Explanation

The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

An older client is hospitalized following an embolic stroke resulting in right-sided paresis. Three days after admission, the nurse notes edema and erythema to the right lower leg. These findings should alert the nurse to which possible condition?

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?