A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves.
Which of the following actions should the nurse take?

Assist the patient into a prone position.

Place a sleeve over the top of each leg with the opening facing up.

Make sure two fingers can fit under the sleeves.

Set the ankle pressure at 65 mm Hg. .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Assisting the patient into a prone position is not necessary for the use of thigh-length sequential compression sleeves. These devices are typically used while the patient is in bed or sitting in a chair.

Choice B rationale

Placing a sleeve over the top of each leg with the opening facing up is not the correct method for applying sequential compression sleeves. The sleeves should be applied so that they fit snugly and comfortably around the patient’s legs.

Choice C rationale

The nurse should ensure that two fingers can fit under the sleeves. This is to ensure that the sleeves are not too tight, which could impede blood flow and cause discomfort or injury to the patient.

Choice D rationale

Setting the ankle pressure at 65 mm Hg is not related to the use of sequential compression sleeves. The pressure settings for these devices are typically determined by the healthcare provider based on the patient’s specific needs.

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Correct Answer is D

Explanation

Choice A rationale: Initiating a cardiac enzyme panel can help determine if the client has had a heart attack. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first. An ECG can provide immediate information, while a cardiac enzyme panel takes longer to return results.

Choice B rationale: Starting intravenous fluid therapy may be necessary depending on the client’s hydration status and overall condition. However, it is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

Choice C rationale: Providing pain relief medication may be necessary if the client is in pain. However, the client’s primary complaint is chest tightness and difficulty breathing, not pain. Therefore, addressing the potential cardiac issue is the priority.

Choice D rationale: The client’s symptoms of sudden shortness of breath, chest tightness, and anxiety, along with her history of hypertension and diabetes, are concerning for a possible cardiac event. An electrocardiogram (ECG) can provide immediate information about the heart’s electrical activity and help identify if the client is experiencing a heart attack or other cardiac event. This should be the first action taken to quickly identify the cause of the client’s symptoms and initiate appropriate treatment.

Choice E rationale: Performing a comprehensive physical assessment is an important part of nursing care. However, in this situation, the client’s symptoms indicate a need for immediate intervention to address her potential cardiac issue.

Choice F rationale: Monitoring the client’s blood glucose levels is important given her history of diabetes. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

A. Admitting diagnosis B. Breath sounds C. Body temperature D. Diagnostic test results

Correct Answer is B

Explanation

When giving a change-of-shift report about a client with pneumonia, the priority piece of information for the nurse to provide is the client’s breath sounds. This is because breath sounds can indicate the severity of the pneumonia and the effectiveness of the treatment. Changes in breath sounds can signal a worsening condition that requires immediate medical attention.

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A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is giving a change-of-shift report about a client they admitted earlier that day who has pneumonia. Which piece of information is the priority for the nurse to provide?

Correct Answer is B

Explanation

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A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves.
Which of the following actions should the nurse take?