a female client taking oral contraceptives reports to the nurse that she is experiencing calf pain what action should the nurse implement

HESI RN

HESI Medical Surgical Practice Exam Quizlet

1. A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement?

A. Determine if the client has also experienced breast tenderness and weight gain.
B. Encourage the client to begin a regular, daily program of walking and exercise.
C. Advise the client to notify the healthcare provider for immediate medical attention.
D. Tell the client to stop taking the medication for a week to see if symptoms subside.

Correct answer: C

Rationale: Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention.

2. The client who experiences angina has been advised to follow a low-cholesterol diet. Which of the following meals would be best?

A. Hamburger, salad, and milkshake.
B. Baked liver, green beans, and coffee.
C. Spaghetti with tomato sauce, salad, and coffee.
D. Fried chicken, green beans, and skim milk.

Correct answer: C

Rationale: The best meal option for a client with angina following a low-cholesterol diet is spaghetti with tomato sauce, salad, and coffee. This meal is lower in cholesterol content compared to the other options provided. Hamburger with salad and milkshake, baked liver with green beans and coffee, and fried chicken with green beans and skim milk are higher in cholesterol and may not be suitable for an individual with angina who needs to adhere to a low-cholesterol diet.

3. A client who was involved in a motor vehicle collision is admitted with a fractured left femur that is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which intervention should the nurse implement?

A. Verify pedal pulses using a Doppler pulse device
B. Evaluate the application of the splint to the left leg
C. Offer ice chips and clear oral liquids
D. Monitor the left leg for pain, pallor, paresthesia, paralysis, pressure

Correct answer: B

Rationale: Evaluating the application of the splint is the priority as it ensures it is not too tight, which could impair circulation and exacerbate the diminished pulses. Verifying pedal pulses with a Doppler pulse device may be indicated but does not directly address the immediate concern of proper splint application. Offering ice chips and clear oral liquids would not address the issue of diminished distal pulses. Monitoring the left leg for pain, pallor, paresthesia, paralysis, and pressure is important but would not directly address the cause of the diminished pulses in this scenario.

4. The nurse is preparing to give trimethoprim-sulfamethoxazole (TMP-SMX) to a patient and notes a petechial rash on the patient’s extremities. The nurse will perform which action?

A. Hold the dose and notify the provider.
B. Request an order for a blood glucose level.
C. Request an order for a BUN and creatinine level.
D. Request an order for diphenhydramine (Benadryl).

Correct answer: A

Rationale: When a patient on TMP-SMX presents with a petechial rash, it can be indicative of a severe adverse reaction such as thrombocytopenia or a hypersensitivity reaction. The appropriate action for the nurse to take in this situation is to hold the dose of TMP-SMX and notify the healthcare provider immediately. This is crucial to prevent further administration of a medication that may be causing a serious adverse effect. Requesting a blood glucose level (Choice B) is not relevant in this scenario as the patient's presentation is suggestive of a skin-related issue rather than a glucose-related problem. Similarly, requesting a BUN and creatinine level (Choice C) would not address the immediate concern of a petechial rash and its association with TMP-SMX. Requesting an order for diphenhydramine (Choice D) may help manage itching or mild allergic reactions but is not the priority when a petechial rash is observed, as it may indicate a more severe reaction requiring immediate intervention.

5. Which client is at greatest risk for coronary artery disease?

A. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago.
B. A 43-year-old male with a family history of CAD and a cholesterol level of 158 (8.8 mmol/L).
C. A 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin.
D. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L).

Correct answer: D

Rationale: The 65-year-old female who is obese with a high LDL level of 188 (10.4 mmol/L) is at the greatest risk for coronary artery disease. Obesity and high LDL cholesterol levels are significant risk factors for developing coronary artery disease. While factors like mitral valve prolapse (choice A) and a family history of CAD (choice B) can contribute to the risk, they are not as significant as obesity and high LDL levels. Choice C, a 56-year-old male with high HDL and taking atorvastatin, is actually at lower risk due to the high HDL levels and being on statin therapy, which helps reduce cholesterol levels and lower the risk of coronary artery disease.