A client who is 2 days postoperative reports severe pain and swelling in the right leg. The nurse notes that the leg is warm and red. What is the nurse's priority action?

Correct Answer: D

Rationale: The correct answer is D: Notify the healthcare provider immediately. This is the priority action because the client is experiencing severe pain, swelling, warmth, and redness in the leg, which are signs of potential deep vein thrombosis (DVT) or other serious complications postoperatively. The healthcare provider needs to be informed promptly to assess and initiate appropriate treatment to prevent further complications. A: Applying a warm compress may worsen the condition if it is DVT, as heat can promote clot formation. B: Elevating the leg on pillows may not address the underlying cause of the symptoms and delay necessary intervention. C: Measuring the circumference of the leg may provide some information, but it is not as urgent as notifying the healthcare provider for immediate assessment and intervention.

Correct Answer: B

Rationale: The correct answer is B: Take the medication 30 minutes before meals. Pyridostigmine is a cholinesterase inhibitor used to treat myasthenia gravis by improving muscle strength. Taking it before meals helps optimize its effects when muscle strength is needed the most during eating. Taking it with food (A) may delay absorption. Avoiding dairy products (C) is not necessary with pyridostigmine. Taking the medication at bedtime (D) may not be optimal for addressing muscle weakness during meal times.

Correct Answer: C

Rationale: The correct answer is C: Numbness and tingling around the mouth. This finding indicates potential hypocalcemia, a common complication post-thyroidectomy due to inadvertent removal of parathyroid glands. Immediate intervention is necessary to prevent severe hypocalcemia symptoms like tetany and seizures. Hoarse voice (A) and difficulty swallowing (B) are expected post-thyroidectomy due to surgical trauma, while sore throat (D) is common from intubation.

Correct Answer: B

Rationale: The correct answer is B: Nausea and vomiting. This finding requires immediate intervention because digoxin toxicity can present with gastrointestinal symptoms like nausea and vomiting. This can indicate an overdose of digoxin, which can be life-threatening. Prompt action is necessary to prevent further complications. A: Heart rate of 58 beats per minute is within the therapeutic range for digoxin and does not require immediate intervention. C: Blood pressure of 130/80 mm Hg is also within normal limits and does not indicate an urgent issue. D: Shortness of breath can be a symptom of heart failure but is not a direct indication of digoxin toxicity requiring immediate intervention.

Correct Answer: C

Rationale: Step-by-step rationale: 1. Deep, rapid respirations in DKA indicate Kussmaul respirations, a compensatory mechanism for metabolic acidosis. 2. Immediate intervention is needed to prevent respiratory failure and further acidosis. 3. Administering IV fluids and insulin can help correct acidosis and stabilize breathing. 4. Fruity breath odor (A) and high blood glucose (B) are common in DKA but do not require immediate intervention. 5. Serum potassium of 5.2 mEq/L (D) is slightly elevated but not as urgent as addressing respiratory distress.