Level: Advanced
Difficulty: Hard
Subtopic: Renal impairment
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to renal impairment. Assessm…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to renal impairment. Assessment data include bilateral calf pain with redness and warmth after bedrest. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that bilateral calf pain with redness and warmth after bedrest.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that bilateral calf pain with redness and warmth after bedrest.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.