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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["28"]
Explanation
(Volume in mL * Drop Factor) / Time in minutes.
Volume is 1,000 mL, the drop factor is 10 gtt/mL, and the time is 6 hours.
First, convert the hours into minutes (6 hours * 60 minutes/hour = 360 minutes). Then, multiply the volume by the drop factor (1,000 mL * 10 gtt/mL = 10,000 gtt).
Finally, divide this number by the total time in minutes (10,000 gtt / 360 minutes ≈ 27.78
gtt/min).
Rounding to the nearest whole number, the nurse should set the manual IV infusion to deliver 28 gtt/min.
Correct Answer is D
Explanation
A. A pH of 7.45 indicates alkalosis, not acidosis. In respiratory acidosis, the pH would be lower than normal (below 7.35) due to the accumulation of carbon dioxide.
B. A bicarbonate (HCO3-) level of 30 mEq/L is within the normal range (typically 22-26 mEq/L). Bicarbonate levels may be normal or slightly elevated in respiratory acidosis as a compensatory mechanism to buffer the excess acid.
C. Potassium levels can vary in respiratory acidosis but are not typically specified by a specific value. The level of potassium is more directly related to metabolic acid-base disturbances rather than respiratory acidosis.
D. An elevated PaCO2 level above 45 mm Hg indicates respiratory acidosis. In this scenario, a PaCO2 of 50 mm Hg suggests that the client is retaining carbon dioxide, leading to an acidotic state (lower pH).
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