When assessing a postoperative client, a nurse finds that there is tenderness, redness, and swelling in the left calf. The nurse should:
A. Massage the lower leg
B. Prepare for heparin therapy
C. Keep the leg in a dependent position
D. Have the client exercise that extremity
B
B. Client complains of calf tenderness; redness, and edema in lower extremity. These are signs and symptoms of venous thrombosis or thrombophlebitis. Notify physician, and anticipate orders for bed rest, leg elevation, and initiation of anticoagulation (e.g., heparin intravenous drip).
A. Do not massage affected leg.
C. Anticipate orders for bed rest, leg elevation, and initiation of anticoagulation (e.g., heparin intravenous drip).
D. Continue to have client do leg exercises with unaffected leg.
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The nurse debriding a wound explains the purpose of debridement is to:
a. increase the effectiveness of the skin graft. b. prevent infection and promote healing. c. promote suppuration of the wound. d. promote movement in the affected area.
The nurse is assessing the fundal height of a pregnant client and notes the fundus is halfway between the symphysis pubis and the umbilicus. The nurse would correctly estimate the weeks in pregnancy as which of the following?
1. 10–12 2. 16 3. 20–22 4. 38
The nurse is caring for a small-for-gestational-age infant born to a drug-dependent patient. For which manifestations should the nurse assess as evidence of withdrawal symptoms in the newborn? (Select all that apply.)
A) Tremors B) Convulsions C) High-pitched cry D) Constant movement E) Sluggish respiratory rate
When caring for a client with cholecystitis, the nurse knows to place the client in which of the following positions?
A) supine B) Trendelenburg C) lithotomy D) Fowler's