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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A listing of African-American women in the community may help identify the target audience but is not as crucial as engaging the community leaders.
Choice B reason: Morbidity data for breast cancer in women of all races provides background information but does not directly address the specific needs of African-American women.
Choice C reason: Technical assistance to produce a video is useful but secondary to involving the community in the planning process.
Choice D reason: Participation of community leaders is vital as they can provide insights into cultural and social factors that influence health behaviors, ensuring the program is culturally relevant and effective.
Correct Answer is ["0.75"]
Explanation
Calculation Steps:
Step 1: Determine the concentration of the reconstituted solution: 0.25 mg/mL. Result = 0.25 mg/mL.
Step 2: Calculate the volume needed for the prescribed dose: 0.1875 mg ÷ 0.25 mg/mL = 0.75 mL.
Result = 0.75 mL.
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