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 D

Explanation

Choice A reason: Monitoring daily sodium intakeis important for long-term management, but does not immediately address acute fluid overload.

Choice B reason: Measuring ankle circumference can help assess fluid retention, but it is not the first intervention. It is more important to address the underlying issue of sodium imbalance.

Choice C reason: Obtaining serum creatinine levels daily can provide information about kidney function but does not directly address the immediate concern of sodium and fluid balance in SIADH.

Choice D reason: Ensuring the client takes a diuretic every morning may be part of the treatment plan, but it is more important to first monitor and manage sodium levels to ensure safe and effective use of diuretics.

A. Prepare the client for a prescribed computed tomography (CT) scan. B. Strain the urine for the presence of stones. C. Obtain a urine specimen for analysis. D. Administer a prescribed opioid analgesic.

Correct Answer is D

Explanation

Choice A reason: Preparing the client for a CT scan is important for diagnostic purposes but is not the immediate priority in managing severe pain.

Choice B reason: Straining the urine for stones is important for confirming the presence of renal calculi but should be done after managing the acute pain.

Choice C reason: Obtaining a urine specimen for analysis is useful for diagnosing infection or other abnormalities but is secondary to pain management.

Choice D reason: Administering a prescribed opioid analgesic is the first priority to relieve the client's severe pain and provide comfort.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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