A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following should the nurse include?
A. Flex
... [Show More] the foot q hr when awake.
B. Place a pillow under the knee when lying in bed.
C. Lower the leg when sitting in a chair.
D. Ensure the leg is abducted when resting in bed.
A. Flex the foot q hr when awake.
The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.
B. Avoid placing pillows under the knee to prevent flexion contractures.
C. Elevate the leg when sitting in a chair to reduce edema and pain.
D. Keep the operative leg in a neutral position when resting in the bed to prevent dislocation of the knee.
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?
A. The chest tube is draining serosanguineous fluid at 65 mL/hr.
B. The client tolerates gentle milking of the tubing.
C. Bubbling in the water seal chamber has ceased.
D. There is tidaling in the water seal chamber.
C. Bubbling in the water seal chamber has ceased.
Bubbling in the water seal chamber ceases when the lung re-expands.
D. The presence of tidaling in the water seal chamber results from the client's inhalation and exhalation and is NOT indicative of lung re-expansion.
A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider?
A. Temperature 37.2 C (99 F)
B. BP 100/70
C. Weight loss
D. Restlessness
D. Restlessness
Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache.
A. An increased temperature is an expected finding for a client who has just completed dialysis. The dialysis machine slightly warms the bloods.
B. A decreased in BP is an expected finding for a client who has just completed dialysis. The decrease is a result of the removal of excess fluid from the client's blood.
C. This is an expected finding after dialysis.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?
A. K+ 3.5 mEq/L
B. pH 7.28
C. BG 272 mg/dL
D. HCO3 14 mEq/L
C. BG 272 mg/dL
A glucose reading <300 mg/dL indicates improvement in the client's status.
A. A K+ level of a client who has DKA might be below, at, or above the expected range.
B. This is an expected finding and does not indicate improvement.
D. This is an expected finding and does not indicate improvement.
A nurse is caring for a client who had a nephrostomy tube inserted 12 hours ago. Which of the following findings should the nurse report to the provider?
A. The client's urinary output has increased.
B. The client reports back pain.
C. The client's urine color is red tinged.
D. The client's BUN is 18 mg/dL.
B. The client reports back pain.
The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged.
A. If there is a decreased UOP, it could indicate impaired renal function or dysfunction of the tube.
C. Red-tinged urine is an expected finding for the first 12 to 24 hr following a nephrostomy tube insertion.
D. WNL
A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the POC?
A. Keep a lead-lined container in the client's room.
B. Limit each visitor to 1 hr per day.
C. Place a dosimeter badge on the client.
D. Remove soiled linens from the client's room each day.
A. Keep a lead-lined container in the client's room.
The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant.
B. Restrict each visitor to 30 min per day to limit exposure to radiation.
C. Staff should wear a dosimeter badge.
D. Keep all soiled linens in the client's room until the client has had the radiation implant removed.
A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)?
A. Temperature 38.9° C (102° F)
B. Systolic blood pressure 70 mm Hg
C. Heart rate 52/min
D. Respiratory rate 8/min
C. Heart rate 52/min
A client who is experiencing AD will exhibit multiple manifestations, including bradycardia, severe headache, and flushing.
A. Manifestations of AD include diaphoresis above the site of the spinal cord injury, but an elevated temperature is NOT a manifestation of AD.
B. A hallmark manifestation of AD is a sudden, significant rise in systolic and diastolic pressures.
D. Anxiety is a manifestations of AD. Therefore, the nurse should expect the client to exhibit tachypnea, rather than bradypnea.
A nurse is planning care for a client who is having modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?
A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period.
B. Assist the client to start arm exercises 48 hr after surgery.
C. Maintain the right arm in an extended position at the client's side when in bed.
D. Place the client in a supine position for the first 24 hr after surgery.
A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period.
The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.
B. The nurse should instruct the client to start exercising the right arm 24 hr after surgery.
C. The nurse should elevate the client's right arm on a pillow to promote lymphatic fluid return.
D. The nurse should elevate the head of the client's bed to at least 30° to promote drainage from the surgical site and facilitate breathing.
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation?
A. Elevated blood pressure
B. Dehydration
C. Stress ulcers
D. Hypernatremia
C. Stress ulcers
Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment.
A. Positive pressure from mechanical ventilation inhibits blood return to the heart, leading to decreased cardiac output and hypotension.
B. Decreased cardiac output associated with mechanical ventilation places the client at risk for fluid retention.
D. Hyponatremia can occur secondary to fluid retention that results from long-term mechanical ventilation. [Show Less]