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 D
Explanation
d. Muscle pain.
Atorvastatin is a medication used to lower cholesterol levels in the blood. One of the potential adverse effects of atorvastatin is myopathy, a condition characterized by muscle pain, weakness, and tenderness. In severe cases, myopathy can progress to rhabdomyolysis, a potentially life-threatening condition in which muscle breakdown products are released into the bloodstream and can cause kidney damage.
Therefore, the nurse should instruct the client to monitor for muscle pain, weakness, or tenderness and report these symptoms to the healthcare provider immediately. Hypoglycemia, palpitations, and daytime drowsiness are not commonly associated with atorvastatin use and would not require immediate reporting to the healthcare provider.
Correct Answer is D
Explanation
Hyperactive bowel sounds refer to an increased intensity, frequency, and loudness of bowel sounds. They are typically described as loud, high-pitched, and occurring more frequently than normal. This can indicate increased bowel motility and may be associated with conditions such as diarrhea, gastroenteritis, or bowel obstruction.
No sounds heard after listening for 3 to 5 minutes: This describes absent or hypoactive bowel sounds, where no sounds or very few sounds are heard. It can indicate decreased or absent bowel motility and may be seen in conditions such as ileus or peritonitis.
Sounds are soft and at a rate of 1/min: This describes normal or hypoactive bowel sounds, where the sounds are relatively quiet and occur at a slower rate (usually 5-34 sounds per minute). It may be observed in situations such as during sleep, after eating, or in certain conditions like constipation or paralytic ileus.
Indicates decreased motility: This is an inaccurate statement for hyperactive bowel sounds.
Hyperactive bowel sounds actually indicate increased motility, as mentioned earlier. Decreased motility would be associated with hypoactive or absent bowel sounds.
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