A client has just returned to the surgical unit following a femoral-popliteal bypass of the right leg. In which position should the nurse place the client?

Supine with the right leg extended and flat.

High-Fowler’s with the right leg extended.

Supine with the right leg flexed at a 45-degree angle.

Semi-Fowler’s with the right leg on two pillows.

Answer and Explanation

The Correct Answer is A

Choice A rationale

After a femoral-popliteal bypass, the client should be placed in a supine position with the right leg extended and flat. This position helps to prevent kinking and occlusion of the graft, which could lead to complications such as graft thrombosis.

Choice B rationale

High-Fowler’s position with the right leg extended is not recommended. This position could put strain on the surgical site and potentially compromise the graft.

Choice C rationale

Supine with the right leg flexed at a 45-degree angle is not advised. Flexing the leg could lead to kinking of the graft and subsequent complications.

Choice D rationale

Semi-Fowler’s with the right leg on two pillows is not the optimal position. While elevation can help with swelling, excessive elevation could potentially compromise blood flow to the graft.

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Correct Answer is B

Explanation

Choice A rationale

Pseudomembranous colitis and crystalluria are not typically associated with gentamicin use.

Choice B rationale

Gentamicin can cause ototoxicity, which can manifest as tinnitus (ringing in the ears), vertigo (a sensation of spinning), and hearing loss. Headaches can also occur as a side effect of gentamicin.

Choice C rationale

While gentamicin can cause nephrotoxicity (kidney damage), which could potentially affect electrolyte levels, a potassium level of 3.5 mg/dL is within the normal range. Therefore, this would not typically be assessed as a toxic effect of gentamicin.

Choice D rationale

Hypoglycemia and cardiac dysrhythmias are not typically associated with gentamicin use.

A. Hold the warfarin until the next day’s dose and notify the laboratory. B. Administer the daily dose of warfarin and notify the healthcare provider so tomorrow’s dose can be adjusted. C. Administer the daily dose of warfarin as these are the expected side effects of the medication. D. Hold the warfarin until the healthcare provider is notified of the assessment findings.

Correct Answer is D

Explanation

Choice A rationale

While holding the warfarin and notifying the laboratory could be appropriate actions in some situations, they would not address the immediate concern of the large, new ecchymotic areas on the client’s extremities.

Choice B rationale

Administering the daily dose of warfarin and notifying the healthcare provider for a dose adjustment the next day could potentially exacerbate the bleeding risk, given the presence of the large, new ecchymotic areas.

Choice C rationale

Large, new ecchymotic areas are not expected side effects of warfarin. They could indicate a serious problem such as excessive anticoagulation.

Choice D rationale

The presence of large, new ecchymotic areas could indicate excessive anticoagulation, which is a serious complication of warfarin therapy. Therefore, holding the warfarin and notifying the healthcare provider of the assessment findings would be the most appropriate initial action.

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A client has just returned to the surgical unit following a femoral-popliteal bypass of the right leg. In which position should the nurse place the client?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is monitoring a client receiving gentamicin. Which of the following would the nurse assess as potential toxic effects of this medication?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities. What should be the nurse’s initial action?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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