A nurse is caring for a client who is about to be discharged to a rehabilitation facility after knee surgery. Which of the following interventions should the nurse expect to find in the client's care plan?

The client should place a pillow under their knee when resting.

The client should take an anticoagulant for 3 days following surgery.

The client should begin to ambulate using a walker or a cane.

The client should begin physical therapy 3 weeks after surgery.

Answer and Explanation

The Correct Answer is C

A. The client should place a pillow under their knee when resting: Placing a pillow under the knee after surgery is generally not recommended because it can promote flexion contractures. Instead, the knee should be kept in a neutral or slightly extended position to maintain proper alignment and prevent stiffness.

B. The client should take an anticoagulant for 3 days following surgery: Anticoagulant therapy after knee surgery is typically prescribed for a longer period, often several weeks, depending on the client’s risk for deep vein thrombosis. A 3-day regimen would be insufficient for most post-operative patients.

C. The client should begin to ambulate using a walker or a cane: Early ambulation with assistive devices is a standard intervention in post-knee surgery rehabilitation. It helps maintain mobility, prevents complications like deep vein thrombosis and muscle atrophy, and promotes joint function while ensuring safety as the client regains strength.

D. The client should begin physical therapy 3 weeks after surgery: Physical therapy usually begins within 24–48 hours post-surgery or as soon as the client is medically stable. Delaying therapy for 3 weeks would hinder recovery, increase stiffness, and delay functional independence.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Assess for bladder distention: A full bladder can prevent the uterus from contracting effectively, leading to a boggy fundus and increased risk of postpartum hemorrhage. Assessing and addressing bladder distention is the priority because it directly impacts uterine tone and hemorrhage prevention.

B. Apply supplemental oxygen via nonrebreather mask: Oxygen may be necessary if the client shows signs of hypoxia or shock, but it does not address the primary cause of a boggy uterus. The priority is to correct the underlying issue affecting uterine contraction.

C. Administer intramuscular methylergonovine: Methylergonovine is used to promote uterine contraction, but pharmacologic intervention should follow initial assessment to identify reversible causes such as bladder distention. Administering medication without assessment could overlook a correctable mechanical issue.

D. Analyze coagulation studies: Coagulation studies are important if bleeding persists or coagulopathy is suspected, but they are not the immediate priority in a client with a boggy fundus shortly after birth. Immediate interventions to promote uterine contraction take precedence.

A. Diarrhea B. Hypoglycemia C. Agranulocytosis D. Urinary frequency

Correct Answer is C

Explanation

A. Diarrhea: Diarrhea is not a common adverse effect of clozapine. Gastrointestinal symptoms may occur with some antipsychotics, but diarrhea is not a primary concern with clozapine therapy.

B. Hypoglycemia: Clozapine is more commonly associated with hyperglycemia and increased risk of diabetes mellitus, rather than hypoglycemia. Blood glucose monitoring may be needed in clients at risk.

C. Agranulocytosis: Clozapine can cause severe neutropenia or agranulocytosis, which increases the risk of infection. Regular monitoring of white blood cell counts is essential, and any signs of infection should prompt immediate evaluation.

D. Urinary frequency: Urinary frequency is not a typical adverse effect of clozapine. Anticholinergic effects like urinary retention are more commonly associated with this medication, rather than increased frequency.

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A nurse is caring for a client who is about to be discharged to a rehabilitation facility after knee surgery. Which of the following interventions should the nurse expect to find in the client's care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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