A prenatal client is experiencing calf pain when she walks. Which action is appropriate for the nurse to implement?
Instruct the client to limit walking episodes.
Tell the client that this is normal during pregnancy.
Gather further assessment data
Instruct the client to elevate the legs consistently throughout the day.
The Correct Answer is C
Rationale:
A. Limiting walking episodes may reduce discomfort but does not address the underlying issue or potential complications.
B. While leg cramps can be common during pregnancy, calf pain could also indicate a more serious condition, such as deep vein thrombosis (DVT), and should not be dismissed as normal without further investigation.
C. Gathering further assessment data is crucial to determine the cause of the calf pain, as it may indicate DVT, a potentially life-threatening condition. The nurse should assess for other symptoms like swelling, redness, or warmth in the leg.
D. Instructing the client to elevate the legs may be appropriate for general discomfort, but without proper assessment, it may not be the correct intervention if DVT is present.
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Correct Answer is A
Explanation
Rationale:
A. A rapid weight gain, such as a 5 lb increase in one day, is a strong indicator of fluid overload, particularly in clients with end-stage kidney disease. This excess fluid retention can lead to complications like pulmonary edema and congestive heart failure.
B. An oxygen saturation of 93% is slightly low but not a direct indicator of fluid overload; it may be related to other factors like anemia or underlying lung disease.
C. Normal skin turgor, where the skin returns to its previous position after being pinched, does not indicate fluid overload. In fluid overload, you might see pitting edema, where the skin does not return immediately.
D. Flattened neck veins would suggest a lack of fluid, not an overload. In fluid overload, you would expect to see distended neck veins (jugular venous distension).
Correct Answer is B
Explanation
Rationale:
A. Bubbling in the water seal chamber with exhalation can be normal as it indicates air is escaping from the pleural space; however, continuous bubbling may indicate an air leak and would need to be assessed.
B. Movement of the trachea toward the unaffected side is a sign of a tension pneumothorax, a life-threatening condition requiring immediate
medical intervention. This tracheal deviation suggests that the pressure in the pleural space is increasing, pushing the mediastinum to the opposite side.
C. Scant serosanguinous drainage on the dressing is expected and not an immediate concern unless it becomes excessive.
D. Crepitus, or subcutaneous emphysema, indicates air leakage into the tissues but is not immediately life-threatening unless it is extensive and worsening rapidly.