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 A

Explanation

Choice A reason: A headache with blurred vision following alteplase administration could indicate intracranial hemorrhage, which requires immediate intervention.

Choice B reason: Lower extremity edema is not typically an immediate concern post-alteplase administration unless it indicates a deep vein thrombosis.

Choice C reason: Paroxysmal supraventricular tachycardia requires monitoring, but it is not as urgent as a headache with blurred vision, which could signify a life-threatening complication.

Choice D reason: Frequent premature ventricular contractions should be monitored, but they are not as critical as a headache with blurred vision post-alteplase.

A. Assume care of the client and assign the PN to the care of a different client. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Acknowledge that the PN has positioned the client safely and correctly. D. Demonstrate to the PN how to position the client more effectively for the procedure.

Correct Answer is D

Explanation

Choice A reason: Assuming care of the client and reassigning the PN does not address the immediate need to correct the client's position for the sigmoidoscopy.

Choice B reason: While assistance may be needed, it is more important to first ensure that the client is in the correct position for the procedure.

Choice C reason: Acknowledging the PN's action would be incorrect since the client has not been positioned safely and correctly for a sigmoidoscopy.

Choice D reason: Demonstrating the correct positioning ensures the procedure can be performed effectively and safely, which is the nurse's immediate responsibility.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is D

Explanation

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