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 A

Explanation

The correct answer is choice A. Instruct the client to lie supine with his knees flexed. Choice A rationale: This position reduces tension on the abdominal incision and can help minimize further protrusion of the abdominal contents. It also facilitates easier coverage of the wound and can help prevent additional injury. Choice B rationale: Semi-Fowler's position is not appropriate in this scenario because it can increase intra-abdominal pressure and exacerbate the evisceration. It may also make it more difficult to manage the protruding organs and to cover the wound adequately. Choice C rationale: Covering the wound with a dry sterile dressing is not sufficient in the case of evisceration. The exposed organs need to be kept moist to prevent tissue drying and damage. Sterile saline-soaked dressings are typically recommended in such cases. Choice D rationale: A transparent dressing is not appropriate for evisceration as it does not provide the necessary moisture and protection. Transparent dressings are more suitable for minor wounds or as secondary dressings but not for exposed internal organs.

A. "You can begin collection of urine after discarding your first morning void." B. "You should eat a protein-rich diet during the collection period." C. "You can cleanse your perineal area with an antiseptic towel each time before you void." D. "You should record your blood glucose level each time you void."

Correct Answer is A

Explanation

The correct answer is A. The client should begin collecting urine after discarding the first morning void, which is not part of the 24-hr period. The client should avoid eating a protein-rich diet during the collection period, as this can affect the creatinine level. The client does not need to cleanse the perineal area with an antiseptic towel each time before voiding, as this is not necessary for a creatinine clearance test. The client does not need to record the blood glucose level each time they void, as this is not related to the creatinine clearance test.

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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

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