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 D

Explanation

A. Heparin should be administered using IV tubing that is specifically labeled for heparin or that has been dedicated for anticoagulant use only. However, this is not the most important action.

B. Heparin is not typically administered as a bolus (large single dose) because of its rapid onset of action and potential for causing bleeding complications. Instead, heparin is usually administered as a continuous IV infusion to achieve and maintain therapeutic anticoagulation.
C. While vitamin K is an antidote for reversing the effects of warfarin (a different type of anticoagulant), it is not used for reversing the effects of heparin. The reversal agent for heparin is protamine sulfate. Therefore, having vitamin K available is not necessary for managing a client receiving heparin.
D. The aPTT is a laboratory test used to monitor the therapeutic effect of heparin therapy. It measures the clotting time of blood and helps ensure that the client's heparin infusion is within the desired therapeutic range. Checking aPTT regularly (usually every 4-6 hours initially, then adjusting based on results) is essential to maintain therapeutic anticoagulation and avoid complications like bleeding or clotting.

A. "My tongue is red and beefy." B. "My vision seems blurry." C. "I am gaining weight." D. "I am constipated."

Correct Answer is B

Explanation

A. This statement suggests symptoms of vitamin B12 deficiency or glossitis, which are not typical signs of digoxin toxicity. Therefore, it is unlikely to indicate digoxin toxicity.
B. Blurred vision is a common neurological symptom of digoxin toxicity. It occurs due to disturbances in visual acuity and color vision, which can manifest as seeing halos around lights or difficulty focusing. Therefore, this statement is indicative of potential digoxin toxicity.
C. Weight gain can occur due to fluid retention, which is a symptom of heart failure rather than digoxin toxicity. Digoxin toxicity typically presents with neurological and gastrointestinal symptoms rather than weight gain.
D. Constipation is not typically associated with digoxin toxicity. Gastrointestinal symptoms such as nausea, vomiting, and anorexia are more common with digoxin toxicity, but constipation is not a specific indicator.

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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

A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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