A nurse is assisting with the care of a client who is 6 hr postoperative following a right total knee arthroplasty. Which of the following actions should the nurse take?
Maintain the head of the client's bed in high-Fowler's position.
Remove the client's dressing when it becomes saturated.
Check the client's pedal pulses every hour.
Place an abductor wedge under the client's right knee.
The Correct Answer is C
A nurse assisting with the care of a client who is 6 hours postoperative following a right total knee arthroplasty should check the client's pedal pulses every hour. This is important to assess the adequacy of blood flow and tissue perfusion to the extremity.
It is also important to monitor the client's pain level, administer pain medication as ordered, and encourage the client to perform exercises as appropriate.
The head of the client's bed should be maintained in a semi-Fowler's position to promote optimal respiratory function, and the client's dressing should be changed only as needed and with sterile technique.
An abductor wedge is not typically used following knee arthroplasty surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as diarrhea, gastroenteritis, or early bowel obstruction.
Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.
Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.
Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.
Correct Answer is A
Explanation
a. "I should discuss this document with my family after I sign it"
Advance directives are legal documents that allow an individual to specify the type of medical care they want to receive in case they become unable to make their own decisions. It is important for the client to discuss their wishes with their family members or loved ones so that they are aware of the client's desires and can act accordingly in case of an emergency.
b. "I am not allowed to change my mind once I sign this document" is incorrect. The client can change their mind about their advance directive at any time and for any reason. It is important for the client to review their advance directive periodically and make changes as necessary.
c. "An atorney will need to notarize this document for it to be valid" is also incorrect. While some states require advance directives to be notarized or witnessed, not all states do. It is important for the client to check with their state's laws regarding advance directives to ensure that their document is legally binding.
d. "My partner needs to be present when I sign this document" is not necessarily true. While it is recommended for the client to have a witness present when signing their advance directive, it does not have to be their partner. The witness should be someone who is not a family member, healthcare provider, or beneficiary of the client's estate.
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