A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to take when a client on bed rest complains of pain and burning in the right calf area is to compare the circumference to the left calf (Option D). The rationale behind choosing this action is based on the suspicion of deep vein thrombosis (DVT) in the right calf. Comparing the circumference of the right calf to the left calf can help in identifying unilateral swelling, which is a common sign of DVT. This assessment is crucial in detecting a potential life-threatening condition early and initiating prompt treatment. Option A, deeply palpating the area for rebound tenderness, is incorrect because rebound tenderness is not a relevant assessment in this context and could potentially cause harm by dislodging a clot if DVT is present. Option B, medicating the client for pain and reassessing in 60 minutes, delays the assessment and treatment of a possible DVT, which can lead to serious complications like pulmonary embolism. Option C, percussing over the area for a change in tone, is not the appropriate assessment for evaluating calf pain and burning in this case. In an educational context, understanding the rationale behind choosing the correct action not only reinforces clinical knowledge but also emphasizes the importance of thorough assessment skills in nursing practice. Recognizing the signs and symptoms of DVT and knowing the appropriate actions to take can significantly impact patient outcomes and safety.

Correct Answer: A

Rationale: In caring for an immobile client, the priority assessment is the auscultation of lung sounds (Option A). This is crucial because immobility can lead to respiratory complications such as pneumonia, atelectasis, or respiratory infections. By assessing lung sounds, the nurse can detect any abnormalities early and intervene promptly to prevent further complications. Assessment of skin turgor (Option B) is important for evaluating hydration status but is not the priority in an immobile client as respiratory issues pose a more immediate threat to health. Auscultation of bowel sounds (Option C) and assessment for peripheral edema (Option D) are also important assessments but do not take precedence over assessing the respiratory status in an immobile client. In an educational context, understanding the priority assessments for immobile clients is essential for providing quality care and preventing complications. Nurses need to prioritize assessments based on the client's condition to ensure timely interventions and promote positive outcomes.

Correct Answer: D

Rationale: The correct answer is D) Stage 2. This wound assessment describes a stage 2 pressure ulcer, which is characterized by a shallow, open ulcer with a reddened base but no slough. In stage 2, the damage extends through the epidermis and into the dermis, presenting as a partial-thickness loss of skin. This stage requires appropriate wound care and monitoring to prevent further complications. Option A) Stage 3 is incorrect because in stage 3, the ulcer extends into the subcutaneous tissue, presenting as a full-thickness wound with possible slough but not through muscle or bone. Option B) Stage 4 is incorrect as stage 4 ulcers involve full-thickness skin loss with extensive tissue damage, potentially reaching muscle or bone. Option C) Stage 1 is incorrect because in stage 1, the skin is intact but may show non-blanchable redness, indicating a risk of pressure injury but not a full ulcer. Understanding wound staging is crucial for nurses to provide appropriate care, prevent complications, and promote healing. Nurses must accurately assess and document wounds to guide treatment decisions and prevent progression to more severe stages. Knowledge of wound staging also helps in communicating effectively with the healthcare team and ensuring consistent care practices.

Correct Answer: D

Rationale: In the context of a client with impaired mobility, the correct nursing intervention to help prevent skin breakdown is option D, which is to turn the client every 2 hours. This intervention is crucial as immobility can lead to prolonged pressure on certain body areas, increasing the risk of pressure ulcers. By regularly repositioning the client, pressure is relieved, promoting circulation and reducing the likelihood of skin breakdown. Option A, assisting the client to orthopneic position, is not directly related to preventing skin breakdown. While positioning is important, it is more about optimizing respiratory function rather than addressing the issue of pressure ulcers. Option B, offering the client a bedpan for toileting, and option C, offering a protein-rich diet, are not directly linked to preventing skin breakdown in a client with impaired mobility. While maintaining good nutrition is important for overall health and healing, it does not directly address the primary concern of pressure ulcer prevention. Educationally, it is essential for nursing students to understand the significance of regular repositioning in clients with impaired mobility to prevent complications like pressure ulcers. This rationale highlights the importance of evidence-based interventions and critical thinking in providing optimal care for clients with specific health challenges.

Correct Answer: A

Rationale: In the scenario of providing oral hygiene for an unconscious client, the priority nursing intervention of positioning the client on one side with the head turned towards you is crucial. This position helps prevent aspiration and facilitates drainage of oral secretions, reducing the risk of choking or aspiration pneumonia. Option B, handling dentures with care, is important but not the priority when compared to ensuring proper positioning for a client who is unconscious. Option C, using gentle techniques for fragile mucosa, is also important but falls secondary to the immediate need for positioning. Option D, having a suction apparatus ready, is essential but should come after ensuring proper positioning to maintain the airway. In an educational context, this question emphasizes the critical thinking skills required in prioritizing nursing interventions based on the client's condition. Understanding the rationale behind each option helps students grasp the importance of assessing and addressing the most urgent needs first to ensure patient safety and well-being.