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. Assessment is the first phase of the nursing process where the nurse collects data about the client's health status, including medical history, current symptoms, and potential allergies. During the assessment phase, the nurse should specifically ask the client about any known allergies to medications, foods, or other substances. This information is crucial for ensuring patient safety during diagnostic testing and any subsequent treatments.
B. The planning phase involves developing a care plan based on the assessment data gathered. While the nurse does consider potential allergies during this phase when planning interventions and care strategies, the primary focus is on creating a plan that addresses the client's specific needs and goals.
C. Implementation is the phase where the nurse carries out the interventions outlined in the care plan. If the client has allergies identified during the assessment phase, the nurse must ensure that these allergies are communicated to the healthcare team and that appropriate precautions are taken during diagnostic testing and any procedures or treatments.

D. Evaluation is the final phase of the nursing process where the nurse assesses the client's response to interventions and determines the effectiveness of the care plan. Although allergies are primarily addressed in the assessment phase, the nurse continues to monitor for allergic reactions throughout the client's care and promptly addresses any concerns that arise.

A. Metabolic acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Respiratory acidosis

Correct Answer is C

Explanation

A. Metabolic acidosis is characterized by a decrease in bicarbonate or an increase in acids, which can be caused by conditions like kidney failure or diabetic ketoacidosis, but it is not typically associated with numbness and tingling.
B. Respiratory alkalosis is characterized by a high pH (>7.45) and a decreased PaCO2 (<35 mm Hg). It typically results from hyperventilation, which leads to excessive elimination of CO2 and subsequent alkalosis. This condition is less likely to occur in gastroenteritis unless there are other complicating factors such as anxiety or pain causing increased respiratory rate.
C. In the context of gastroenteritis, where there may be a loss of stomach acids through vomiting or diarrhea, the most likely acid-base imbalance would be metabolic alkalosis.
D. Respiratory acidosis is characterized by a low pH and an elevated PaCO2 (>45 mm Hg). It results from hypoventilation, leading to retention of CO2 and subsequent acidosis. Respiratory acidosis would not typically present with numbness and tingling in the extremities in the context of gastroenteritis.

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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 in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is A

Explanation

A nurse is admitting a client who has gastroenteritis and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances?

Correct Answer is C

Explanation

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