A client had a right knee replaced 4 days ago. The client returns with an elevated temperature for the past 24 hours. Which assessment would the nurse prioritize?
Urine characteristics
Homan's sign
Lung sounds
Frequency of diarrhea episodes
The Correct Answer is C
A. While monitoring urine characteristics is important for overall assessment, it may not be the priority in this situation.
B. Homan's sign is used to assess for deep vein thrombosis and may not be directly related to the client's current symptoms.
C. Elevated temperature after knee replacement surgery could indicate a potential infection, including pneumonia, so assessing lung sounds for signs of infection is a priority.
D. Diarrhea may be indicative of gastrointestinal issues but is less likely to be directly related to the client's current symptoms after knee replacement surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}
Explanation
A. Placing the client on Contact Precautions is appropriate to prevent the transmission of MRSA to other patients and healthcare workers.
B. Applying a cold compress may worsen tissue damage and compromise blood flow, which can exacerbate the wound infection and cellulitis.
C. Elevating the client's arm can help reduce swelling and improve circulation, aiding in the resolution of cellulitis.
D. Taking a wound culture every shift is not necessary or useful, as it can be painful for the client and does not provide timely information on the infection status. A wound culture is usually done once before starting antibiotic therapy and then repeated only if there is no improvement or signs of worsening.
E. Initiating IV access for fluid and antibiotic therapy is necessary for treating the systemic infection caused by MRSA and cellulitis.
F. Subcutaneous sodium heparin is an anticoagulant that prevents blood clots, but it is not indicated for this client unless they have a history or risk of thromboembolic events, such as deep vein thrombosis or pulmonary embolism.
Correct Answer is D
Explanation
A. While generalized malaise can occur with inflammatory conditions, it is not a hallmark symptom of ankylosing spondylitis.
B. Ankylosing spondylitis primarily affects the spine and sacroiliac joints, not typically the ankles.
C. Deformities of fingers and toes are not characteristic of ankylosing spondylitis; they are more commonly associated with conditions like rheumatoid arthritis.
D. Ankylosing spondylitis is characterized by progressive stiffness and fusion of the spine, leading to decreased mobility and flexibility, especially in the lower back.
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