A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

Encourage increased fluid take.

Promote bed rest for 5-7 days.

Place a pillow under the affected limb.

Apply cool compresses to the affected limb every 6 hr.

Answer and Explanation

The Correct Answer is D

A.   Encouraging adequate fluid intake is important postoperatively to maintain hydration and support normal physiological functions. However, the amount of fluid intake should be within the client's tolerance and as prescribed by the healthcare provider. It helps prevent complications such as dehydration and promotes circulation, which is beneficial for wound healing.

B.   While some rest and limited mobility are initially recommended after knee replacement surgery to allow for healing and to prevent complications, prolonged bed rest for 5-7 days is not typically necessary or recommended. Early mobilization and gradual increase in activity are encouraged to prevent complications such as deep vein thrombosis and to promote recovery.
C.   Placing a pillow directly under the knee is not recommended as it can lead to decreased range of motion and potential contractures.
D.   Cold therapy, such as applying cool compresses, is often used to reduce swelling and pain in the initial postoperative period. It can help manage pain and discomfort and promote comfort for the client.

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Correct Answer is A

Explanation

A. Troponin is a protein found in cardiac muscle cells. When there is damage to the heart muscle, such as during a myocardial infarction (heart attack), troponin is released into the bloodstream. Therefore, elevated troponin levels in the blood indicate myocardial injury or damage.
B. Troponin is not an enzyme; it is a protein. While there are enzymes such as creatine kinase (CK) and lactate dehydrogenase (LDH) that can indicate damage to various tissues including heart and skeletal muscles, troponin specifically indicates cardiac muscle damage.
C. Troponin is not involved in oxygen transport. Hemoglobin, found in red blood cells, is the protein responsible for oxygen transport in the body.
D. Troponin is not a lipid; it is a protein. Lipids include substances like cholesterol and triglycerides. Troponin levels do not reflect the risk for coronary artery disease; rather, they indicate acute damage to the heart muscle.

Correct Answer is ["300"]

Explanation

To calculate the volume of IV fluids infused from 0330 to 0600, you would determine the number of hours that have passed.

From 0330 to 0600 is 2.5 hours. Since the IV is infusing at 120 mL/hr, you would multiply the infusion rate by the number of hours. So, 120 mL/hr * 2.5 hours = 300 mL.

Therefore, the nurse should record 300 mL of IV fluids on the intake record at 0600.

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A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

Correct Answer is ["300"]

Explanation

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