A nurse is providing ongoing postoperative care to a client who has had knee surgery. The nurse assesses the dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next?
Reassure the family that this is a common problem.
Apply a pressure dressing and report findings.
Document the data and apply a new dressing.
Make assessments every 15 minutes for 4 hours.
The Correct Answer is B
A. Reassuring the family without addressing the issue is unsafe.
B. Applying a pressure dressing helps control bleeding, and reporting findings promptly ensures timely medical intervention.
C. Simply documenting and changing the dressing without addressing bleeding risks worsening the condition.
D. Waiting to monitor without immediate intervention could allow the client’s condition to deteriorate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Incontinence and infrequent changing of adult diapers increase the risk of altered skin integrity, such as skin breakdown or pressure ulcers, due to prolonged exposure to moisture and irritation.
B. The Answer seems incomplete ("risk") and does not specify the type of risk.
C. Activity intolerance is not directly related to incontinence or diaper use.
D. While falls risk is important in older adults, it is not the primary concern related to incontinence and diaper changing.
Correct Answer is A
Explanation
A. Diuretics increase urine output, which can lead to decreased fluid volume (dehydration) and electrolyte imbalances. Teaching the client to monitor fluid intake and signs of dehydration is important.
B. Diuretics do not cause altered urinary elimination in the sense of retention; they actually increase elimination.
C. Altered skin integrity is not a direct concern related to diuretic use.
D. Urinary retention is unlikely with diuretic therapy, which promotes increased urine output.
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