The nurse is caring for a client with lymphangitis of the right leg who is receiving treatment with a broad-spectrum antibiotic. The nurse is giving a bath and observes the right leg is larger than it was 2 hours ago and the client feels hot
What is the first action by the nurse? A) Place the leg below the level of the heart.
B) Notify the physician.
C) Place cool compresses on the extremity.
D) Begin performing passive range of motion exercises.
B
Feedback:
The nurse notifies the physician if the affected area appears to enlarge, additional lymph nodes become involved, or body temperature remains elevated. In severe cases with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The leg should be elevated to reduce the edema. A warm compress may be applied to promote comfort and enhance circulation. Passive range of motion would be contraindicated at this time.
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The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a P wave. This particular arrhythmia can progress into:
a. atrial fibrillation and possible emboli. b. sinus tachycardia and syncope. c. ventricular tachycardia and death. d. sinus bradycardia and fatigue.
Daily weights are being recorded for the patient. His urine output has been less than his intravenous and oral intake. His weight yesterday was 97.5 kg. This morning it is 99 kg. The nurse understands that this corresponds to a(n):
a. fluid retention of 1.5 liters. b. fluid loss of 1.5 liters. c. equal intake and output due to insensible losses. d. fluid loss of 0.5 liters.
If a late postpartum hemorrhage is documented on a client who delivered 3 days ago, the nurse recognizes that this hemorrhage occurred:
a. on the first postpartum day. b. during recovery phase of labor. c. during the third stage of labor. d. on the second postpartum day.
You are part of a team who cares for patients with eating disorders. As a team, what is the main priority in the care plan for someone with an eating disorder?
A) Meeting on a daily basis to discuss manipulative behaviors you observe in the patient B) Restrict the patient to bedrest until the first weight-gain goal is reached C) Allow unlimited exercise and weight training D) Weigh the patient twice daily