Moby's Med/Surg

While convalescing from abdominal surgery a client develops thrombophlebitis. which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply 1. Pain in the calf 2. Intermittent claudication 3. Redness in affected area 4. Pitting edema 5. Ecchymotic areas around the ankle 6. localized warmth in the lower extremity

1,3,6 Rational: 1. Pain in r/t the edema associated with the inflammatory response. 2. Intermittent claudication (pain when walking, resluting from tissue ischemia) may occur with peripherial arterial disease. 3. redness is r/t vasodilation and the inflammatory response. 4. although some localized edema occurs, pitting edema does not occur in thrombophlebitis. 5. ecchymosis is a sign of bleeding; thrombophlebitis is caused by a clot. 6. thrombophlebitis is inflammation of a vien that occurs with the formation of a clot. warmth is r/t vasodilation.

A client is being treated for hypertension reorts having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this clients medications? 1. ACE inhibitors 2. Thiazide diuretics 3. Calcium Channel Blockers 4. Angiotensin receptor blockers

1. ACE Inhibitors

A client who had surgery 24 hrs ago reorts pain in the calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do? 1. keep both legs dependent 2. Notify the HCP 3. Aply a warm soak to the left calf 4. administer the prescribed analgesic

2. Notify the HCP Rational: Clinical findings indicate a possible thrombophlebitis. Bed rest with legs elevated should be maintained and the health care provider notified immediately. A thrombus may progress to a pulmonary embolus.

After abdominal surgery a client suddenly reorts numbness in the right leg and a funny feeling in the toes. what should the nurse do first? 1. elevate the legs and tell the client to drink more water 2. instruct the client to remian in bed and notify the HCP 3. rub the clients legs to stimulate circulation and cover the client with a blanket 4. tell the client about the dangers of prolonged bed rest and encourage ambulation

2. instruct the client to remian in bed and notify the HCP Rational: localized sensory changes may inidcate nerve damage, impaired circulation, or thrombophlebitis. activity should be limited and HCP notified.

A nurse in the ostanesthesia care unit is caring for a client who recieved general anesthetic. Which finding should the client report to the health care provider? 1. Client pushes the airway out. 2. Client has snoring respirations 3. Respirations of 16 breaths/ min are shallow 4. Systolic BP drops from 130 to 90

4. Systolic BP drops from 130 to 90. Rational: A drop in B ; rapid pulse rate; cold clammy skin; & oliguria are signs of decreased blood volume and shock, which if not tx promptly can lead to death.

After Bilateral lumbar sympathectomy a client has a sudden drop in BP, but there is no evidence of bleeding. What should the nurse identify as the most likely cause of the change in BP? 1. inadaquete fluid intake 2. consequence of anesthesia 3. increased level of epinephrine 4. relallocation of all the blood supply

4. reallocation of the blood supply Rational: a sympathectomy causes dilation of the blood vessels in the lower extremities; the resulting shift in the blod volume lowers the systemic blood pressure.