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 C

Explanation

Choice A reason: While sodium intake can affect blood pressure, this response does not address the importance of frequent blood pressure monitoring in the context of acute glomerulonephritis.

Choice B reason: Hypotension leading to sudden shock is not a common complication of acute glomerulonephritis; instead, hypertension is more likely due to fluid retention and kidney impairment.

Choice C reason: Elevated blood pressure is a significant concern in acute glomerulonephritis due to fluid retention and decreased kidney function. Early identification and management of hypertension are crucial to prevent complications such as seizures or heart failure.

Choice D reason: Blood pressure fluctuations do not necessarily indicate that the condition has become chronic. Frequent monitoring is necessary to manage acute symptoms and prevent complications.

A. Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client. B. Introduce him to the newly admitted client and ask him to join in the conversation. C. Encourage him to go to the nurse's station and talk with another nurse. D. Inform him that the nurse is busy admitting a new client and will talk to him later.

Correct Answer is D

Explanation

Choice A reason: Ignoring the client can escalate the behavior, as individuals with antisocial behavior may act out more to gain attention.

Choice B reason: Introducing him to the newly admitted client and asking him to join the conversation can disrupt the admission process and does not address the client's behavior appropriately.

Choice C reason: Encouraging him to go to the nurse's station and talk with another nurse may be an option, but it does not directly address the client's need for immediate attention.

Choice D reason: Informing him that the nurse is busy and will talk to him later sets clear boundaries and allows the nurse to complete the admission process without disruption.

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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

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Correct Answer is C

Explanation

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Correct Answer is D

Explanation

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