A nurse is planning care for a client who is 6 hr postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's plan of care?

Apply warm, moist packs to the surgical site.

Place a pillow under the client's surgical knee

Use the continuous passive-motion machine intermittently.

Massage the lower leg in smooth, long strokes.

Answer and Explanation

The Correct Answer is C

The correct answer is C.

Using the continuous passive-motion machine intermittently helps to prevent joint stiffness and promote circulation in the surgical leg. Applying warm, moist packs to the surgical site can increase inflammation and infection risk. Placing a pillow under the client's surgical knee can cause flexion contractures and impair healing. Massaging the lower leg in smooth, long strokes can dislodge a thrombus and cause a pulmonary embolism.

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Correct Answer is B

Explanation

The correct answer is B. "You have a right to change your mind." This response respects the client's autonomy and informs them that they can reconsider their decision if they wish. The other responses are inappropriate and should be avoided. "If I were you, I would contact your spiritual director." implies that the nurse does not support the client's decision and tries to persuade them to change it. "Making this decision is wrong." is judgmental and disrespectful of the client's beliefs and values. "I'm sure that everything will be allright, regardless of your decision." is false reassurance and minimizes the potential consequences of the client's decision.

A. Changing the appliance on a new colostomy B. Performing indwelling urinary catheter care C. Demonstrating how to use an incentive spirometer D. Measuring the depth of a stage 3 pressure injury

Correct Answer is B

Explanation

The correct answer is choice b. Performing indwelling urinary catheter care.

Choice A rationale:

Changing the appliance on a new colostomy is a complex task that requires assessment and education, which should be performed by a registered nurse (RN) or a licensed practical nurse (LPN).

Choice B rationale:

Performing indwelling urinary catheter care is a routine task that can be delegated to an assistive personnel (AP) as it involves basic hygiene and maintenance.

Choice C rationale:

Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient’s technique, which should be done by an RN or LPN.

Choice D rationale:

Measuring the depth of a stage 3 pressure injury requires assessment skills and clinical judgment, which are beyond the scope of practice for an AP. This task should be performed by an RN or LPN.

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A nurse is planning care for a client who is 6 hr postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Correct Answer is B

Explanation

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