A registered nurse is providing ongoing post-operative care to a client who has had knee surgery. The nurse assesses the surgical dressing and finds it saturated with blood. The client is restless and has a rapid pulse.
What should the nurse do next?

Make assessments every 15 minutes for four hours.

Document the data, remove the old dressing and apply a new dressing.

Apply a well-secured additional pressure dressing and report findings.

Reassure the family that this is a common problem.

Answer and Explanation

The Correct Answer is C

Rationale for Choice A:
Making assessments every 15 minutes for four hours does not directly address the immediate concern of blood loss and potential hemodynamic instability. While close monitoring is essential, it's not the primary action in this situation.
Excessive blood loss can rapidly lead to hypovolemic shock, which requires prompt intervention to prevent serious complications.
Relying solely on frequent assessments without active interventions could delay crucial treatment and compromise patient safety.
Rationale for Choice B:
Documenting the data, removing the old dressing, and applying a new dressing might be necessary at some point, but it's not the most urgent priority in this case.
Removing the dressing could disrupt clot formation and potentially worsen bleeding.
Applying a new dressing without addressing the underlying bleeding might not effectively control the blood loss. Rationale for Choice C:
Applying a well-secured additional pressure dressing is the most appropriate immediate action to help control bleeding and prevent further blood loss.
It provides direct compression to the surgical site, promoting hemostasis and reducing blood flow. This action prioritizes stabilizing the patient's condition and preventing further complications.

Reporting the findings to the healthcare provider is crucial for timely assessment, diagnosis, and management of potential complications, such as hemorrhage or hematoma.
It ensures collaboration with the healthcare team and facilitates appropriate interventions based on the patient's specific needs.
Rationale for Choice D:
Reassuring the family that this is a common problem might provide some comfort, but it doesn't address the patient's immediate needs or the potential severity of the situation.
It's essential to prioritize patient safety and provide interventions to control bleeding, even if bleeding is a known potential complication.
Transparency and clear communication with the family are important, but they should not replace necessary medical interventions.

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Correct Answer is C

Explanation

Choice A rationale:
Circular turns involve wrapping the bandage around the limb in a continuous circle, with each layer overlapping the previous one. While this technique is effective for securing dressings on cylindrical body parts like the arm or thigh, it's not ideal for joints like the ankle. Circular turns can constrict movement and potentially impair circulation, especially if applied too tightly. Additionally, they don't provide adequate compression for wounds that require it.
Choice B rationale:
Figure-of-eight turns create a cross-over pattern around the joint, resembling the number 8. This technique offers better flexibility and movement compared to circular turns, but it's still not the most appropriate for the ankle. The cross-over pattern can create uneven pressure points and potentially lead to discomfort or even skin irritation. Moreover, it might not provide sufficient compression for wound management.
Choice C rationale:
Spiral turns involve wrapping the bandage diagonally, ascending or descending the limb, with each layer overlapping the previous one by about half its width. This technique is considered the most suitable for bandaging joints like the ankle for several reasons:
Conforms to Joint Contours: Spiral turns naturally mold to the shape of the ankle, providing even pressure distribution and avoiding constriction points. This ensures comfort and maintains proper blood flow.
Allows for Movement: The diagonal pattern accommodates the natural flexion and extension of the ankle joint, allowing for greater mobility without compromising bandage integrity.
Provides Effective Compression: Spiral turns can be applied with varying degrees of compression to suit the needs of the wound and surrounding tissue. This can help control bleeding, reduce swelling, and promote healing.
Easy to Apply and Adjust: Spiral turns are relatively straightforward to apply and can be easily adjusted if needed, making them adaptable to different wound sizes and patient needs.
Choice D rationale:
Recurrent bandaging involves wrapping the bandage back and forth over the same area multiple times, creating a thicker layer. This technique is primarily used for stumps or areas requiring significant padding and absorption. It's not typically used for bandaging joints like the ankle, as it can create excessive bulk and potentially restrict movement.

A. Reduced kidney ability to concentrate urine. B. Lower fluid intake during daytime hours. C. Enhanced bladder contractility leading to urinary stasis. D. Increased bladder muscle tone leading to frequent urination.

Correct Answer is A

Explanation

Choice A rationale:
Reduced kidney ability to concentrate urine is a common physiological change associated with normal aging. This is due to several factors, including:

Decreased glomerular filtration rate (GFR): The kidneys filter waste products from the blood. As we age, the number of functioning nephrons (filtering units) in the kidneys decreases, leading to a decline in GFR. This means that the kidneys are less able to filter waste products and concentrate urine.
Decreased renal blood flow: Blood flow to the kidneys also decreases with age. This further reduces the kidneys' ability to filter waste products and concentrate urine.
Decreased tubular function: The tubules in the kidneys are responsible for reabsorbing water and electrolytes from the urine. As we age, the function of the tubules also declines, leading to a decrease in the ability to concentrate urine.
As a result of these changes, older adults often produce more urine, even at night. This can lead to nocturia, which is the need to wake up to urinate two or more times per night.
Choice B rationale:
Lower fluid intake during daytime hours can also contribute to nocturia, but it is not a direct physiological change associated with normal aging. Older adults may drink less fluids during the day for a variety of reasons, such as decreased thirst sensation, fear of incontinence, or limited access to fluids. However, even if they maintain adequate fluid intake during the day, they may still experience nocturia due to the reduced ability of their kidneys to concentrate urine.
Choice C rationale:
Enhanced bladder contractility leading to urinary stasis is not a typical physiological change associated with normal aging. In fact, bladder contractility often decreases with age, which can lead to difficulty emptying the bladder completely. This can contribute to urinary frequency and urgency, but it is not typically a cause of nocturia.
Choice D rationale:
Increased bladder muscle tone leading to frequent urination is also not a typical physiological change associated with normal aging. Bladder muscle tone may decrease with age, which can lead to difficulty emptying the bladder completely. However, it is not typically a cause of nocturia.

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A registered nurse is providing ongoing post-operative care to a client who has had knee surgery. The nurse assesses the surgical dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client has an open wound on the right ankle that the registered nurse has cleansed and dressed with gauze. The nurse now needs to apply a conforming ace bandage to keep the dressing in place. What technique will the nurse use to apply the bandage on the ankle?

Correct Answer is C

Explanation

An elderly resident of a long-term care facility frequently wakes up to urinate during the night. What physiological change associated with normal aging could be the cause of this?

Correct Answer is A

Explanation

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A registered nurse is providing ongoing post-operative care to a client who has had knee surgery. The nurse assesses the surgical dressing and finds it saturated with blood. The client is restless and has a rapid pulse.
What should the nurse do next?