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"]

Explanation

Choice A reason: Obtaining a clean catch urine sample for culture and sensitivity is crucial for identifying the specific bacteria causing the infection and determining the appropriate antibiotic treatment.

Choice B reason: Initiating broad spectrum IV antibiotics is important to start treating the infection immediately, especially given the severity of the symptoms.

Choice C reason: Collecting a serum sample for hemoglobin and hematocrit is not immediately necessary in this scenario. The focus should be on diagnosing and treating the infection.

Choice D reason: Giving diphenhydramine prep for intravenous pyelogram is not relevant to the immediate management of the client's condition.

Choice E reason: Forcing oral fluids can help flush out the urinary system, but it is not the most critical initial intervention compared to obtaining a urine culture and starting antibiotics.

A. Twin siblings admitted with scarlet fever that is complicated with pneumonia. B. A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB). C. An older client with scabies who is admitted from an extended care facility. D. A female adolescent admitted with multiple genital Herpes simplex II lesions.

Correct Answer is B

Explanation

Choice A reason: Scarlet fever and pneumonia require droplet precautions, not airborne.

Choice B reason: A positive Mantoux test and positive sputum cultures for AFB indicate tuberculosis, which requires airborne precautions and a negative airflow room.

Choice C reason: Scabies requires contact precautions, not airborne.

Choice D reason: Genital Herpes simplex II requires standard precautions, not airborne.

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

Explanation

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Correct Answer is B

Explanation

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