An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy once a day. Which problem should the nurse identify as a priority for this patient?
Potential complication, Fluid and electrolyte imbalance
Potential complication: venous thromboembolism
Potential complication: Impaired surgical wound healing
Potential complication: hypovolemic shock
The Correct Answer is B
Venous thromboembolism refers to the formation of blood clots in the veins, which can lead to serious complications such as pulmonary embolism. After surgery, immobility and reduced activity can increase the risk of developing blood clots. Therefore, it is crucial to prioritize measures to prevent venous thromboembolism, such as early mobilization, compression stockings, and anticoagulant medications, to ensure the patient's safety and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
In a child with acute appendicitis, it is common to observe an elevated white blood cell count (WBC) as a response to the infection or inflammation associated with the condition. The neutrophil count may be within the lower end of the normal range or slightly decreased, as it can be affected by the severity and duration of the appendicitis. The red blood cell count (RBC) appears to be within the normal range. The lactic acid level is normal, indicating no significant metabolic acidosis.
Correct Answer is C
Explanation
The assessment findings indicate that the client has diminished lung sounds in the lower lobes, suggesting potential postoperative atelectasis or decreased air movement in the lungs. Using an incentive spirometer can help improve lung expansion and prevent respiratory complications such as pneumonia. It is important to address this issue promptly to prevent further deterioration of lung function.
Administering pain medication may be necessary depending on the client's level of pain, but addressing the respiratory issue takes priority in this situation.
Administering the antibiotic earlier than scheduled or changing the dressing over the wound may not be indicated based on the provided assessment findings.
Therefore, having the client use the incentive spirometer is the most appropriate action at this time to promote optimal lung function and prevent respiratory complications.
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