When assessing a postoperative patient, the nurse notes tenderness, redness, and swelling in the left calf. What should the nurse do next?
a. Massage the lower leg.
b. Contact the surgeon and prepare for heparin therapy.
c. Keep the leg in a dependent position.
d. Have the patient exercise that extremity.
B
Calf tenderness, redness, and edema in the lower extremity are signs and symptoms of venous thrombosis or thrombophlebitis. Notify the surgeon and anticipate orders for bed rest, leg elevation, and initiation of anticoagulation (e.g., heparin intravenous drip). Do not massage the affected leg. Continue to have the patient do leg exercises with the unaffected leg, not the affected leg.
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Arterial blood gases were drawn when a patient was discovered in cardiopulmonary arrest. Which results would the nurse evaluate as indicating global lactic acidosis?
1. pH 7.21 2. HCO3 24 mEq/L 3. Base excess -12 mmol/L 4. PaO2 82 mm Hg 5. PaCO2 37 mm Hg
The family of a critically ill client tells the nurse that the client believes in divine intervention and their faith will sustain them until the client recovers. The nurse realizes this family and client demonstrate which of the following?
1. Denial 2. Conflict 3. Spiritual health 4. Good family support system
Patients with peripheral vascular disease
A. heal poorly. B. have strong pulses. C. have high blood pressure. D. have thin toenails.
The mother of a teenage client who has an adjustment disorder with depressed mood mentions, "I'm glad we're getting the problems taken care of now so we won't have to worry about de-pression in the future."
The information about risk that should serve as a basis for the nurse's reply is: 1. Early intervention with teen problems prevents future problems as an adult 2. Diagnosis of teen adjustment disorder may predict problems as an adult 3. No information exists that will help the nurse frame an answer 4. Unless the client has first-rank relatives with depression, risk is limited