Try Naxlex NCLEX-RN (Free-Trial)

Patient Data

Based on the client’s history and assessment findings, which of the following are priority nursing concerns for this client? Select all that apply.

Left lower extremity pain and cramping after activity

Cool, shiny, hairless left leg with delayed capillary refill

Numbness and tingling in the left lower extremity

Dependent rubor of the left foot

History of type 2 diabetes mellitus

Intermittent productive cough for 20 years

Edema in the left lower extremity

Answer and Explanation

Correct Answer : A,B,C,D

Rationale:
A. Left lower extremity pain and cramping after activity: Pain and cramping with ambulation, especially worsening and lasting longer than usual, indicate intermittent claudication and potential progression of peripheral arterial disease (PAD). This is a priority concern because it reflects impaired perfusion and ischemia.

B. Cool, shiny, hairless left leg with delayed capillary refill: These signs indicate chronic arterial insufficiency and decreased tissue perfusion. The risk of tissue damage, ulceration, or gangrene makes this a high-priority nursing concern.

C. Numbness and tingling in the left lower extremity: Neurologic symptoms such as paresthesia reflect ischemia and nerve compromise. Prompt assessment and monitoring are essential to prevent complications like peripheral neuropathy or tissue injury.

D. Dependent rubor of the left foot: Dependent rubor is a classic sign of PAD indicating poor arterial blood flow and oxygenation. This is an urgent finding that reflects vascular compromise and risk for critical limb ischemia.

E. History of type 2 diabetes mellitus: While diabetes is an important risk factor for PAD, it is a chronic condition rather than an immediate priority for acute nursing concern in this admission.

F. Intermittent productive cough for 20 years: Chronic cough may indicate COPD or chronic bronchitis, but it is not the immediate priority compared to signs of acute limb ischemia.

G. Edema in the left lower extremity: Mild dependent edema is noted but is likely secondary to positioning rather than a primary vascular concern. It is lower priority compared with ischemic signs and symptoms.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. A retraining program will need to be initiated when the child returns home: Most children experience temporary regression during hospitalization due to stress, illness, or disruption of routines. Formal retraining is rarely necessary once the child returns to a familiar environment. Immediate concerns should focus on emotional support rather than structured retraining.

B. Diapering will be provided since hospitalization is stressful to preschoolers: While diapers may be used temporarily for safety and convenience, routine diapering is not the primary strategy. The focus should be on supporting the child’s developmental skills and reassuring parents about normal regression.

C. Children usually resume their toileting behaviors when they leave the hospital: Regression in toilet habits is a common, temporary response to stress, unfamiliar routines, and illness. Once the child returns home and normal routines are restored, most preschoolers spontaneously regain their previous level of toileting independence. This information reassures parents and normalizes the behavior.

D. A potty chair should be brought from home to maintain the current level of toileting skills: While familiar objects can provide comfort, regression is typically situational and temporary. Bringing a potty chair may be helpful but is not essential for restoring previously established skills. Normal routines at home usually suffice.

A. Encourage consumption of protein and vitamin C. B. Apply thromboembolism deterrent stockings (TED). C. Suggest that client ambulate often. D. Administer antibiotics. E. Use petroleum based lotion on skin. F. Instruct incentive spirometry use every hour.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}

Explanation

Rationale:

• Administer antibiotics: The client presents with left lower leg erythema, warmth, swelling, and a recent skin break, consistent with cellulitis. The presence of elevated WBC count (14.7 x 10⁹/L) supports an infectious process. Early administration of cefazolin IV is indicated to treat the bacterial infection and prevent progression to systemic infection or sepsis.

• Encourage consumption of protein and vitamin C: Adequate nutrition, including protein and vitamin C, supports wound healing and immune function. The client has a small scab and ongoing infection; protein is necessary for tissue repair, and vitamin C contributes to collagen synthesis and immune response. Supporting nutrition enhances recovery from cellulitis.

• Instruct incentive spirometry use every hour: Incentive spirometry is primarily indicated for clients at risk for pulmonary complications, particularly after surgery or with immobility. This client has no current pulmonary compromise or respiratory risk beyond baseline, so frequent incentive spirometry is nonessential.

• Use petroleum based lotion on skin: Petroleum-based lotion may increase skin moisture and maceration, particularly in an area of infection, which can worsen bacterial proliferation. Applying such products to an inflamed or broken area is contraindicated. Skin integrity must be protected without creating an environment favorable to infection.

• Suggest that client ambulate often: Frequent ambulation is contraindicated in the acute phase of cellulitis with leg swelling and pain. Increased movement may exacerbate edema, pain, or tissue injury. Bedrest or limited activity until infection stabilizes reduces the risk of complications such as cellulitis spread or ulceration.

• Apply thromboembolism deterrent stockings (TED): TED stockings are contraindicated in this client because applying compression over an acutely infected, edematous lower extremity can worsen tissue perfusion and increase discomfort. Compression should be avoided in infected or inflamed limbs until infection resolves. Applying TEDs could exacerbate local edema and pain.

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

Patient Data Based on the client’s history and assessment findings, which of the following are priority nursing concerns for this client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 3-year-old client was successfully toilet trained prior to admission to the hospital for injuries sustained from a fall. The client's parents are very concerned that the child has regressed in toileting behaviors. Which information should the nurse provide to the parents?

Correct Answer is C

Explanation

Patient Data For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}

Explanation

The nurse notes that a client with depression has been more withdrawn and non communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

An older adult client with a history of cataracts is recovering from intraocular lens implant (IOL) surgery to the left eye. During the postprocedure period, which intervention should the nurse implement?

The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full leg cast, which action should the nurse prioritize?

The nurse prepares to educate the client and spouse. Click to select the 3 items that the nurse should include in the plan of care after administration of tissue plasminogen activator (tPA).

Patient Data Based on the client's symptoms, the nurse is considering what might be causing them. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse determines that the symptom of dropdown indicates dropdown.

The nurse reviews the information from the initial assessment and history and physical. Which 6 findings in the client's history should the nurse recognize as risk factors for a cerebrovascular event?

Patient Data

Based on the client’s history and assessment findings, which of the following are priority nursing concerns for this client? Select all that apply.