Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?

Correct Answer: C

Rationale: The correct answer is C. New onset shortness of breath is concerning for a pulmonary embolism, a serious complication of VTE. The nurse should act immediately to assess the patient's respiratory status and initiate appropriate interventions. A: Report of right calf pain is expected with VTE and does not require immediate action. B: Erythema of right lower leg can be a sign of inflammation but does not necessitate urgent intervention. D: Temperature of 100.4° F is a low-grade fever, which may indicate an infection but does not require immediate action in this context.

Correct Answer: C

Rationale: The correct answer is C because assessing the patient's intake, output, and daily weight provides direct information on fluid balance. Intake measures fluid coming in, output measures fluid going out, and daily weight reflects changes in total body water. Blood pressure and pulse (A) are affected by various factors and may not solely indicate fluid status. Serum potassium and sodium levels (B) are affected by multiple factors, not just fluid volume. Measurements of abdominal girth and calf circumference (D) are more specific to assessing for fluid retention in certain areas, not overall fluid volume status.

Correct Answer: C

Rationale: The correct question to ask first is "Do you experience shortness of breath with basic activities?" because it directly assesses the client's current health status related to COPD, which is essential for immediate care. By prioritizing this question, the nurse can quickly evaluate the severity of the client's symptoms and determine the need for urgent intervention or adjustment of the care plan. This information is crucial for addressing the client's immediate respiratory needs and ensuring their safety. Choice A is incorrect because assessing the client's support system is important but not as urgent as evaluating their respiratory status. Choice B is also incorrect as understanding the disease is important but not as time-sensitive as assessing the client's current symptoms. Choice D is incorrect as knowing the medications the client is prescribed is important for overall care but does not address the immediate need for respiratory assessment.

Correct Answer: B

Rationale: The correct answer is B: Cool, clammy skin. Following a myocardial infarction, the client may experience hypotension due to decreased cardiac output. Cool, clammy skin indicates poor peripheral perfusion, a common manifestation of hypotension. This finding suggests inadequate blood flow to the skin. The other choices are incorrect because: A: A heart rate of 120 beats/min may indicate tachycardia, which is a compensatory mechanism to maintain cardiac output in response to hypotension. C: An oxygen saturation of 90% is below the normal range but is not a typical assessment finding related to hypotension after a myocardial infarction. D: A respiratory rate of 8 breaths/min is abnormally low but not directly related to hypotension post-myocardial infarction.

Correct Answer: B

Rationale: The correct answer is B, a 52-year-old in a tripod position using accessory muscles to breathe. This client is likely experiencing respiratory distress, which is a medical emergency in COPD. The tripod position and use of accessory muscles indicate increased work of breathing and potential respiratory failure, requiring immediate assessment and intervention to prevent further deterioration. Incorrect choices: A: Smoking history is relevant but does not indicate immediate respiratory distress. C: Dependent edema and clubbed fingers suggest advanced disease but not acute respiratory distress. D: Chronic cough and thick secretions are common in COPD but do not indicate acute respiratory compromise.