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
Displacement is a defense mechanism where a person redirects their emotional impulses, such as anger or frustration, from the original source to a less threatening or more accessible target. In this scenario, the client is redirecting their anger towards the nurse when medication changes are prescribed by the provider. The nurse becomes the target of the client's anger, even though the nurse is not directly responsible for the medication changes.
Conversion is a defense mechanism where psychological distress is expressed as physical symptoms or ailments.
Splitting is a defense mechanism where a person sees things as either all good or all bad, with no middle ground or ambivalence.
Sublimation is a defense mechanism where unacceptable impulses or behaviors are channeled into socially acceptable and constructive outlets.
Correct Answer is C
Explanation
A.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
B.Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
C.Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe..
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today