A nurse is assisting with the care of a client who is 6 hr postoperative following a right total knee arthroplasty. Which of the following actions should the nurse take?
Maintain the head of the client's bed in high-Fowler's position.
Remove the client's dressing when it becomes saturated.
Check the client's pedal pulses every hour.
Place an abductor wedge under the client's right knee.
The Correct Answer is C
A nurse assisting with the care of a client who is 6 hours postoperative following a right total knee arthroplasty should check the client's pedal pulses every hour. This is important to assess the adequacy of blood flow and tissue perfusion to the extremity.
It is also important to monitor the client's pain level, administer pain medication as ordered, and encourage the client to perform exercises as appropriate.
The head of the client's bed should be maintained in a semi-Fowler's position to promote optimal respiratory function, and the client's dressing should be changed only as needed and with sterile technique.
An abductor wedge is not typically used following knee arthroplasty surgery.
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Related Questions
Correct Answer is B
Explanation
It is important to provide choices for the client, but limit them to two or three options to prevent confusion and decision-making difficulties.
Use visual cues to assist the client with locating the bathroom, such as pictures or color-coded signs instead of written signs.
Avoid using confrontation to manage the client's behavior, as it can increase agitation and aggression. Instead, use redirection and positive reinforcement.
Provide a calm and non-stimulating environment for the client, as overstimulation can lead to confusion and agitation.
Correct Answer is A
Explanation
a. Clean the stoma using an inward to outward circular motion.
When providing tracheostomy care, the nurse should clean the stoma using an inward to outward circular motion to remove any secretions or debris. It is important to avoid using excessive force or pressure, which can cause trauma to the stoma. Cleansing the inner cannula with isopropyl alcohol may be appropriate for some clients, but it is important to follow the healthcare provider's orders regarding inner cannula care.
When securing the tracheostomy ties, the nurse should ensure that there is enough space for two fingers, not three. Finally, the nurse should prepare sterile supplies before removing the inner cannula to ensure that they are readily available and reduce the risk of infection.
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