How it Works
Try Naxlex NCLEX-RN (Free-Trial)

The client has returned from surgery following a below the knee amputation (BKA). The residual limb is covered with a compression dressing. Immediately upon return from surgery, the dressing is dry. Thirty minutes later, a small amount of bloody drainage is noted on the dressing. What should be the nurse's priority action at this time?

A.

Change the dressing

B.

Notify the physician

C.

Lower the head of the bed

D.

Mark the area of drainage, time and date

Answer and Explanation

The Correct Answer is D

A.    While it is important to maintain a clean and dry dressing, changing it immediately may not be necessary at this stage. The small amount of bloody drainage could be a normal postoperative finding, and changing the dressing could disturb the surgical site.
B.    While it is important to keep the physician informed of any changes, in this case, a small amount of bloody drainage may not warrant immediate notification unless it becomes excessive or is accompanied by other concerning symptoms.
C.    Lowering the head of the bed might not directly address the situation. It may be more appropriate if the patient shows signs of hypotension or distress, but there is no indication that the drainage has caused such a concern at this moment.
D.    Marking the area of drainage allows for proper monitoring of the situation. It helps track whether the drainage increases, remains the same, or decreases over time. Documentation of the time and date also provides a clear record for the healthcare team regarding the postoperative course, which is essential for ongoing assessment.
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["A","B","C"]

Explanation

A. This statement is correct and crucial. Completing the full course of antibiotics is essential to ensure the infection is fully treated and to prevent antibiotic resistance.
B. Metronidazole can cause a disulfiram-like reaction (similar to what occurs with alcohol and disulfiram) if alcohol is consumed during treatment or shortly after. Symptoms can include flushing, nausea, vomiting, and palpitations.
C. Metronidazole can potentially reduce the effectiveness of hormonal contraceptives. Using a barrier method, like condoms, can help prevent unintended pregnancy during treatment.
D. This statement is not necessary. Metronidazole is not typically associated with crystalluria or the need to strain urine for crystal fragments. This instruction does not apply to this medication.
E. This statement is inaccurate. While metronidazole can cause darkening of the urine, it is not specifically known to change urine to pale yellow. Typically, discoloration could be more of a brown or dark color, and pale yellow is not a common effect of this medication.

Correct Answer is B

Explanation

A. Sun exposure is not related to drug metabolism, and excessive sun exposure can be harmful.
B. Increasing fluid intake can help prevent kidney damage, a potential side effect of trimethoprim- sulfamethoxazole.
C. While it's important to take medications consistently, there's no specific requirement to take trimethoprim-sulfamethoxazole at the same time as hydrochlorothiazide. The dosing schedule should be as prescribed by the healthcare provider.
D. Kaopectate can interfere with the absorption of certain medications and may not be effective in preventing diarrhea caused by trimethoprim-sulfamethoxazole.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register