The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

Fat emboli.

Deep vein thrombosis.

Infection.

Pulmonary embolism.

Answer and Explanation

The Correct Answer is B

Choice A reason: Fat emboli are typically associated with long bone fractures and not commonly linked with dehydration or immobility.

Choice B reason: Deep vein thrombosis (DVT) is a common condition in immobile patients, and redness and swelling in the calf are classic signs.

Choice C reason: While infection can cause redness and swelling, it is usually accompanied by other signs such as fever, which is not mentioned here.

Choice D reason: Pulmonary embolism is a complication that can arise from DVT but would not be the direct cause of calf redness and swelling.

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Correct Answer is D

Explanation

Choice A reason: Waiting until after the procedure to assess for discomfort does not ensure client safety during the procedure itself. While pain assessment is important, it is not the priority safety intervention in this situation, especially since the client is already mildly confused and could disrupt the sterile field or injure themselves if not properly guided.

Choice B reason:Instructing a mildly confused client to keep their hands under the sterile field is likely to be ineffective and potentially dangerous. A confused client may not be able to follow or remember complex instructions, increasing the risk of contaminating the sterile field or causing injury. Instead, a nurse or assistant should physically stay near the client's hands to guide them.

Choice C reason: Pouring cleansing solution onto the sterile cloth field would contaminate the sterile setup, since fluids should only be poured into sterile containers or basins. This action could compromise the sterile field and increase infection risk, making it unsafe practice.

Choice D reason:Verification of informed consent is a critical safety intervention that must occur before any invasive procedure. Since the client is mildly confused, the nurse must ensure that the client had the capacity to consent or that a legal proxy provided it. Proceeding without verifying consent is a legal risk and violates the client's autonomy and safety protocols.

A. Chewable children's aspirin will help prevent inflammation. B. Any level of fever is serious and should be reported right away. C. Keep the child home from daycare for the next two days. D. Apply a cool pack to the injection site to reduce discomfort.

Correct Answer is D

Explanation

Choice A reason: Children's aspirin is not recommended due to the risk of Reye's syndrome and is not typically used for post-vaccination care.

Choice B reason: While fever can occur after vaccination, not all fevers are serious and can often be managed at home unless they are high or persistent.

Choice C reason: Keeping the child home from daycare is not necessary unless the child is feeling unwell or has a fever.

Choice D reason: Applying a cool pack to the injection site is a common recommendation to reduce discomfort and swelling after vaccinations.

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The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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