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","B","C","E"]

Explanation

A. Postoperative patients often experience muscle tension and discomfort due to lying in one position for an extended period. A gentle back massage can help relieve muscle stiffness, promote relaxation, and improve circulation. It is a non-invasive comfort measure that can enhance the client's overall well- being.
B. Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques are beneficial postoperatively as they encourage relaxation and improve overall comfort.
C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) or pneumonia due to shallow breathing or inadequate lung expansion. Coughing and deep breathing exercises help to clear secretions, improve lung function, and prevent respiratory complications. It is typically recommended to perform these exercises every hour to maintain lung expansion and prevent complications.
D. Encouraging the client to turn every 2 hours (D), not every 4 hours, is essential to prevent pressure ulcers and promote circulation.
E. Postoperative pain management is essential for the client's comfort and recovery. Pain can interfere with the client's ability to cough, deep breathe, and move effectively, which may increase the risk of complications. Administering analgesics as needed helps to control pain, improve overall comfort, and promote participation in necessary activities such as coughing, deep breathing, and turning.

A. Apply a warm compress to the IV site. B. Apply firm pressure to the plunger of the syringe during the IV flush to improve patency. C. Remove the IV saline lock. D. Inject the solution more slowly while flushing the IV saline lock

Correct Answer is D

Explanation

A. Applying a warm compress can help dilate the blood vessels, potentially improving circulation around the IV site. This can sometimes alleviate discomfort caused by irritation or infiltration. However, if there is significant pain or swelling, warm compresses may not be sufficient.
B. Applying firm pressure on the syringe plunger during the flush is not recommended. Excessive force could potentially cause damage to the vein or exacerbate pain and discomfort. It's important to flush gently to maintain patency and avoid causing further irritation or complications.
C. If the client reports pain above the IV saline lock and there are signs of infiltration (such as swelling, coolness, or blanching of the skin around the site), removing the IV saline lock may be necessary. Infiltration occurs when IV fluid leaks into the surrounding tissue instead of flowing into the vein, which can lead to discomfort and complications.
D. Injecting the solution more slowly during the flush can help minimize discomfort and reduce the risk of causing further damage. Slower infusion allows for better tolerance by the vein and surrounding tissues, decreasing the likelihood of pain or infiltration.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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