The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?

Confirm that the continuous passive motion device is intact.

Withhold next scheduled dose of low molecular weight heparin.

Determine if the wound drainage device is functioning correctly.

Monitor the client's current white blood cell count (WBC).

Answer and Explanation

The Correct Answer is C

Choice A reason: Confirming the continuous passive motion device is intact is important but secondary to assessing the source of the drainage.

Choice B reason: Withholding the next dose of low molecular weight heparin should only be done based on a healthcare provider's order after assessing the situation.

Choice C reason: Determining if the wound drainage device is functioning correctly is essential to manage the excessive drainage and ensure that there is no blockage or malfunction.

Choice D reason: Monitoring the client's WBC count is important for detecting infection but is not the immediate action required for managing active drainage.

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

Explanation

Choice A reason: The sedimentation rate (ESR) is a common test used to detect inflammation associated with conditions such as rheumatoid arthritis. An elevated ESR indicates the presence of inflammation in the body.

Choice B reason: Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific for rheumatoid arthritis and are useful in confirming the diagnosis. The presence of these antibodies can help distinguish RA from other inflammatory conditions.

Choice C reason: D-Dimer is primarily used to rule out thrombotic conditions such as deep vein thrombosis and pulmonary embolism. It is not specifically related to the diagnosis or management of rheumatoid arthritis.

Choice D reason: C-reactive protein (CRP) is another marker of inflammation that is often elevated in rheumatoid arthritis. It provides information about the level of inflammation and can be used to monitor disease activity and response to treatment.

Choice E reason: While a white blood cell count can provide general information about infection or inflammation, it is not specific to rheumatoid arthritis and is not as useful as the other tests mentioned for diagnosing or managing RA.

A. Hold urine for at least 10 minutes to dilute bacteria. B. Empty the bladder before and after sexual intercourse. C. Drink large amounts of fluids before bedtime. D. Cleanse the perineal area in a circular motion after voiding.

Correct Answer is B

Explanation

Choice A reason: Holding urine for at least 10 minutes does not dilute bacteria and can actually increase the risk of infection.

Choice B reason: Emptying the bladder before and after sexual intercourse helps flush out bacteria that may have been introduced during intercourse, reducing the risk of UTI.

Choice C reason: Drinking large amounts of fluids before bedtime is not specific to preventing UTIs and may lead to nighttime urination, disrupting sleep.

Choice D reason: Cleansing the perineal area in a circular motion is not the recommended method. The recommended practice is to wipe from front to back to prevent the spread of bacteria from the rectal area to the urethra.

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The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

Correct Answer is B

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

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