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 C

Explanation

A. Keep all four of the side rails raised on the client's bed: Raising all four side rails can increase the risk of injury if the client attempts to climb over them. Full side rails are not a recommended fall-prevention strategy for clients with orthostatic hypotension.

B. Check the client every 4 hr to evaluate their need to use the restroom: Checking every 4 hours may not be frequent enough to prevent falls related to sudden episodes of dizziness or urgency. More proactive measures, such as assisting with ambulation, are safer for clients at risk.

C. Instruct the client to stand in place when beginning ambulation: Having the client stand in place for a few moments allows blood pressure to stabilize before walking, reducing the risk of dizziness and falls caused by orthostatic hypotension. This is a key intervention for fall prevention in at-risk clients.

D. Maintain the client's bed at the nurse's waist level: The bed height should be adjusted to facilitate safe transfers, typically at the level that allows feet to touch the floor and promotes stability. Keeping the bed at the nurse's waist level does not specifically prevent falls due to orthostatic hypotension.

A. Unstageable B. Stage 2 C. Stage 3 D. Stage 4

Correct Answer is C

Explanation

A. Unstageable: An unstageable pressure injury occurs when the full thickness of tissue loss is obscured by slough or eschar. Since subcutaneous fat and tunneling are visible in this case, the injury can be staged and is not unstageable.

B. Stage 2: Stage 2 pressure injuries involve partial-thickness skin loss with exposed dermis. They do not extend into subcutaneous tissue and do not present with tunneling or visible fat, so this stage does not fit the description.

C. Stage 3:A Stage 3 pressure injury involves full-thickness skin loss. At this stage, subcutaneous fat (adipose tissue) is visible within the ulcer. Features like tunneling (a narrow opening or passageway extending from the wound) and undermining (tissue destruction underneath the intact skin at the wound edge) are common. However, the nurse should not be able to see bone, tendon, or muscle; if these deeper structures were visible, the injury would be classified as Stage 4.

D. Stage 4:A Stage 4 pressure injury involves full-thickness skin and tissue loss. The distinguishing factor for Stage 4 is the direct visualization or palpation of fascia, muscle, tendon, ligament, cartilage, or bone within the ulcer. While tunneling can occur in Stage 4, the presence of only subcutaneous fat keeps this specific injury at Stage 3.

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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

A nurse is caring for a client who is at risk for a fall because of orthostatic hypotension. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client's coccyx area and notes visible subcutaneous fat with tunneling. Which of the following pressure injury stages should the nurse document?

Correct Answer is C

Explanation

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