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 A

Explanation

A. The ethics committee can provide guidance on how to navigate the conflict between the healthcare provider’s beliefs and the client's documented wishes. The committee can mediate discussions and help ensure that the client's rights and preferences are respected according to legal and ethical standards.
B. While having resuscitation equipment available might be relevant if there is a sudden need for emergency intervention, it does not directly address the issue of honoring the client’s living will. This action does not resolve the ethical conflict or ensure that the client’s wishes are respected.
C. Documenting the healthcare provider’s refusal is important for legal and medical records but does not resolve the situation or ensure that the client’s wishes are respected. Documentation alone does not address the ethical conflict or take action to honor the client’s living will.
D. Facilitating a meeting between the healthcare provider and the spouse could be beneficial for discussing the client’s wishes and potentially reaching a mutual understanding. However, if the healthcare provider remains unwilling to honor the living will despite such discussions, this action alone may not resolve the conflict.

A. Tell the client to use larger bags that expand with gas. B. Teach the client how to burp the bag to relieve the gas. C. Ensure that the pin holes are made at the top of the bag. D. Inform the client about bags that have gas release valves.

Correct Answer is D

Explanation

A. Using larger bags might help accommodate the gas more comfortably and reduce the need for making pinholes. However, this solution does not address the immediate issue of gas accumulation and may not be practical for all clients.
B. "Burping" the bag is a recognized technique for managing gas in colostomy bags. It involves opening the end of the bag slightly to release gas, which helps to prevent the bag from ballooning and causing discomfort. This method is effective and safe, as it is specifically designed to manage gas without compromising the integrity of the bag.
C. Making pinholes in the colostomy bag is not a recommended practice. Pinholes can lead to leakage and increase the risk of skin irritation or infection. While ensuring the pinholes are at the top might reduce some complications, it does not solve the fundamental issue and poses a risk to the client's health and hygiene.
D. Colostomy bags equipped with built-in gas release valves are designed specifically to manage gas accumulation safely and effectively. Informing the client about these specialized bags provides a practical solution to the problem of gas buildup and avoids the risks associated with making pinholes.

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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

Correct Answer is A

Explanation

A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

Correct Answer is D

Explanation

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