Page 806 - Saunders Comprehensive Review For NCLEX-RN

261. Answer: 3

Rationale: Thrombosis of superficial veins usually is accompanied by signs and
symptoms of inflammation, including swelling, redness, tenderness, and warmth of
the involved extremity. It also may be possible to palpate the enlarged, hard vein.
Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is
a normal finding.
Test-Taking Strategy: Eliminate option 4 first because this is a normal and
expected finding. Next, eliminate options 1 and 2 because they are comparable or
alike.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Maternity: Postpartum
Health Problem: Maternity: Infection/Inflammation
Priority Concepts: Clotting; Perfusion
Reference: McKinney et al. (2018), p. 612.

262. Answer: 4

Rationale: If pulmonary embolism is suspected, oxygen should be administered, 8
to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is
kept on bed rest with the head of the bed slightly elevated to reduce dyspnea.
Morphine sulfate may be prescribed for the client, but this would not be the initial
nursing action. An intravenous line also will be required, and vital signs need to be
monitored, but these actions would follow the administration of oxygen.
Test-Taking Strategy: Note the strategic word, initial. Use the ABCs—airway,
breathing, and circulation—to assist in directing you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Respiratory: Pulmonary Embolism
Priority Concepts: Gas Exchange; Perfusion
Reference: McKinney et al. (2018), pp. 608-609.

263. Answer: 3

Rationale: If bleeding is excessive, the cause may be laceration of the cervix or
birth canal. Massaging the fundus if it is firm would not assist in controlling the
bleeding. Trendelenburg’s position should be avoided because it may interfere with
cardiac and respiratory function. Although the nurse would record the findings, the
initial nursing action would be to notify the OB.
Test-Taking Strategy: Note the strategic word, initial. Focus on the data in the
question, noting the clinical manifestations identified in the question. Eliminate
option 2 first because, if the uterus is firm, it would not be necessary to perform
fundal massage. Knowing that Trendelenburg’s position interferes with cardiac and

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