A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

Encourage increased fluid take.

Promote bed rest for 5-7 days.

Place a pillow under the affected limb.

Apply cool compresses to the affected limb every 6 hr.

Answer and Explanation

The Correct Answer is D

A.   Encouraging adequate fluid intake is important postoperatively to maintain hydration and support normal physiological functions. However, the amount of fluid intake should be within the client's tolerance and as prescribed by the healthcare provider. It helps prevent complications such as dehydration and promotes circulation, which is beneficial for wound healing.

B.   While some rest and limited mobility are initially recommended after knee replacement surgery to allow for healing and to prevent complications, prolonged bed rest for 5-7 days is not typically necessary or recommended. Early mobilization and gradual increase in activity are encouraged to prevent complications such as deep vein thrombosis and to promote recovery.
C.   Placing a pillow directly under the knee is not recommended as it can lead to decreased range of motion and potential contractures.
D.   Cold therapy, such as applying cool compresses, is often used to reduce swelling and pain in the initial postoperative period. It can help manage pain and discomfort and promote comfort for the client.

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Correct Answer is D

Explanation

A. Completing an incident report may be necessary if the refusal could potentially impact patient care or if there are policies or procedures in place that require documenting such incidents. It helps to document the details of the refusal and any subsequent actions taken.
B. If the AP refuses to take the specimen, the nurse may need to take responsibility for ensuring the specimen is delivered to the laboratory promptly. This ensures that patient care activities are not delayed and that necessary diagnostic tests are performed in a timely manner.
C. Reporting the refusal to the charge nurse or supervisor is appropriate, especially if there are concerns about the AP's behavior or if it is part of the facility's policy to escalate such incidents. The charge nurse can then address the situation and determine the appropriate course of action.

D. Communicating with the AP to understand their concerns is essential. It allows the nurse to clarify any misunderstandings, address any issues or barriers the AP may have, and potentially resolve the situation collaboratively. It's important to listen to the AP's perspective and provide clarification or reassurance if needed.

A. "My tongue is red and beefy." B. "My vision seems blurry." C. "I am gaining weight." D. "I am constipated."

Correct Answer is B

Explanation

A. This statement suggests symptoms of vitamin B12 deficiency or glossitis, which are not typical signs of digoxin toxicity. Therefore, it is unlikely to indicate digoxin toxicity.
B. Blurred vision is a common neurological symptom of digoxin toxicity. It occurs due to disturbances in visual acuity and color vision, which can manifest as seeing halos around lights or difficulty focusing. Therefore, this statement is indicative of potential digoxin toxicity.
C. Weight gain can occur due to fluid retention, which is a symptom of heart failure rather than digoxin toxicity. Digoxin toxicity typically presents with neurological and gastrointestinal symptoms rather than weight gain.
D. Constipation is not typically associated with digoxin toxicity. Gastrointestinal symptoms such as nausea, vomiting, and anorexia are more common with digoxin toxicity, but constipation is not a specific indicator.

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A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?

Correct Answer is B

Explanation

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