The nurse is caring for a client who had a total hip replacement four (4) days ago. Which assessment requires the nurse’s immediate attention?
A. I have bad muscle spasms in my lower leg of the affected extremity.
B. “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”
C. “I have to use the bedpan to pass my water at least every 1 to 2 hours.”
D. “It seems that the pain medication is not working as well today.”
Answer: B: “I just can’t ”catch my breath” over the past few minutes and I think I am in grave danger.”
The nurse would be concerned about all of these comments. However, the most life-threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life-threatening.
A. I have bad muscle spasms in my lower leg of the affected extremity.
B. “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”
C. “I have to use the bedpan to pass my water at least every 1 to 2 hours.”
D. “It seems that the pain medication is not working as well today.”
Answer: B: “I just can’t ”catch my breath” over the past few minutes and I think I am in grave danger.”
The nurse would be concerned about all of these comments. However, the most life-threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life-threatening.
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Practice Exam