A nurse is assisting in the care of the client who is postoperative following a fasciotomy.

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Prepare to obtain a wound culture.

Restrict fluid intake.

Administer an analgesic

Prepare to administer an antibiotic

Initiate supplemental oxygen.

Answer and Explanation

Correct Answer : A,C,D

A. Prepare to obtain a wound culture: A culture is necessary if infection is suspected.
B. Restrict fluid intake: Contraindicated as hydration is important to support healing and kidney function.
C. Administer an analgesic: Pain management is crucial postoperatively.
D. Prepare to administer an antibiotic: Antibiotics are indicated for infection prophylaxis or treatment.
E. Initiate supplemental oxygen: Not needed unless signs of respiratory distress or hypoxia are present.

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Correct Answer is D

Explanation

A. Turn the client every 4 hr for 48 hr while on bed rest: Clients should be turned more frequently, typically every 2 hours, to prevent complications like pressure injuries and venous thromboembolism. Additionally, clients are often mobilized early postoperatively to reduce complications.
B. Have the client use an incentive spirometer every 4 hr: Incentive spirometry should be performed more frequently (every 1-2 hours) to prevent atelectasis and improve lung function post-surgery.
C. Instruct the client to bend from the hip when retrieving items from the floor: This motion risks hip dislocation. Clients should be instructed to avoid bending at the hip past 90 degrees.
D. Maintain hip abduction when turning the client. Maintaining hip abduction prevents dislocation of the prosthetic hip joint. This position keeps the hip joint in a neutral and stable alignment.

A. Apply pressure to the venipuncture site with sterile gauze. B. Perform hand hygiene. C. Clamp the IV tubing. D. Withdraw the catheter from the client's vein. E. Remove the dressing and tape from the venipuncture site.

Correct Answer is B,E,C,A,D

Explanation

Correct order:

Perform hand hygiene.
Remove the dressing and tape from the venipuncture site.
Clamp the IV tubing.
Apply pressure to the venipuncture site with sterile gauze.
Withdraw the catheter from the client's vein.

Rationale:

Hand hygiene is the first step to prevent infection before touching any equipment or the client.
Removing the dressing and tape is done after hand hygiene to expose the IV insertion site, preparing it for removal.
Clamping the IV tubing helps stop the infusion and prevents blood from flowing out when the catheter is removed.
Applying pressure with sterile gauze helps to prevent bleeding and hematoma formation after the catheter is removed.
Withdrawing the catheter should be the final step to complete the procedure.

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A nurse is assisting in the care of the client who is postoperative following a fasciotomy. Exhibits Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client following a total hip arthroplasty. Which of the following interventions should the nurse recommend?

Correct Answer is D

Explanation

A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B,E,C,A,D

Explanation

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A nurse is assisting in the care of the client who is postoperative following a fasciotomy.

Exhibits

Which of the following actions should the nurse take? Select all that apply.