A nurse is caring for a client who is about to be discharged to a rehabilitation facility after knee surgery. Which of the following interventions should the nurse expect to find in the client's care plan?

The client should place a pillow under their knee when resting.

The client should take an anticoagulant for 3 days following surgery.

The client should begin to ambulate using a walker or a cane.

The client should begin physical therapy 3 weeks after surgery.

Answer and Explanation

The Correct Answer is C

A. The client should place a pillow under their knee when resting: Placing a pillow under the knee after surgery is generally not recommended because it can promote flexion contractures. Instead, the knee should be kept in a neutral or slightly extended position to maintain proper alignment and prevent stiffness.

B. The client should take an anticoagulant for 3 days following surgery: Anticoagulant therapy after knee surgery is typically prescribed for a longer period, often several weeks, depending on the client’s risk for deep vein thrombosis. A 3-day regimen would be insufficient for most post-operative patients.

C. The client should begin to ambulate using a walker or a cane: Early ambulation with assistive devices is a standard intervention in post-knee surgery rehabilitation. It helps maintain mobility, prevents complications like deep vein thrombosis and muscle atrophy, and promotes joint function while ensuring safety as the client regains strength.

D. The client should begin physical therapy 3 weeks after surgery: Physical therapy usually begins within 24–48 hours post-surgery or as soon as the client is medically stable. Delaying therapy for 3 weeks would hinder recovery, increase stiffness, and delay functional independence.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","E","G","H","I"]

Explanation

Rationale for correct choices

• Sudden onset of dyspnea and chest discomfort: These symptoms may indicate acute cardiopulmonary compromise such as pulmonary embolism, acute heart failure, or infection. Sudden dyspnea in a post-op orthopedic client requires immediate assessment and intervention to prevent deterioration.

• Tachypnea and appearance of distress: Rapid, labored breathing indicates the client is struggling to maintain adequate oxygenation and may signal hypoxemia or respiratory failure. Immediate follow-up is necessary to prevent further compromise.

• Crackles heard in bilateral lungs: Bilateral crackles suggest fluid accumulation in the alveoli, possibly from pulmonary edema or early pneumonia. This finding correlates with respiratory distress and requires prompt evaluation.

• S3 and S4 heart sounds noted: Extra heart sounds can indicate left ventricular dysfunction or volume overload, suggesting acute heart failure. Timely assessment is critical to prevent worsening cardiac output and pulmonary congestion.

• Temperature 38.9° C (102° F): Fever indicates possible infection, which in a post-operative patient could suggest pneumonia, surgical site infection, or sepsis. Early recognition and treatment are essential.

• Heart rate 112/min: Tachycardia may be a compensatory response to hypoxia, fever, or fluid overload. Persistent elevation increases cardiac workload and risk of decompensation.

• Respiratory rate 34/min: A significantly elevated respiratory rate confirms respiratory distress and inadequate oxygenation, warranting immediate intervention such as supplemental oxygen adjustment or further diagnostics.

Rationale for incorrect choices

• Client is awake and oriented x4: The client’s alertness and orientation indicate that cerebral perfusion and cognitive function are intact at this time. While this is important to note, it does not indicate acute cardiopulmonary compromise or a life-threatening event, so it does not require immediate follow-up.

• Surgical site is dressed, dry, and intact: The dressing being clean, dry, and intact indicates there is currently no active bleeding or wound complication. While ongoing monitoring is important post-operatively, this finding does not necessitate urgent intervention compared with the client’s acute respiratory and cardiovascular symptoms.

A. Tachycardia B. Headache C. Increased appetite D. Pupil constriction

Correct Answer is A

Explanation

A. Tachycardia: Amphetamines are central nervous system stimulants that increase sympathetic nervous system activity. Tachycardia is a common manifestation of acute toxicity, along with hypertension, hyperthermia, and agitation. Monitoring cardiovascular status is essential to prevent complications.

B. Headache: While headaches can occur with amphetamine use, they are not a primary or consistent finding in acute toxicity. More prominent signs are cardiovascular and neurological stimulation rather than mild symptoms like headache.

C. Increased appetite: Amphetamines typically suppress appetite rather than increase it. Clients experiencing acute toxicity are more likely to have decreased hunger due to stimulant effects on the hypothalamus.

D. Pupil constriction: Amphetamines usually cause mydriasis (pupil dilation) due to sympathetic stimulation. Pupil constriction is more characteristic of opioid toxicity rather than amphetamine toxicity.

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A nurse is caring for a client who is about to be discharged to a rehabilitation facility after knee surgery. Which of the following interventions should the nurse expect to find in the client's care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D","E","G","H","I"]

Explanation

A nurse is assessing a client who is experiencing acute amphetamine toxicity. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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