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 D
Explanation
Rationale:
A. Adjusting the rate of the bladder irrigation might be necessary, but it is not the first action to take when there is no drainage.
B. Ambulating the client can help promote bladder function, but it is not the immediate priority when assessing catheter function.
C. Notifying the provider is important if the issue cannot be resolved, but the nurse should first attempt to resolve common, simple issues like a kinked tube.
D. Checking the tubing for kinks is the most immediate and logical first action to take. Kinks in the tubing can obstruct urine flow, and correcting this can often resolve the issue without further intervention.
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).