A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
Encourage the client to avoid wearing shoes at home.
Place a throw rug over electrical cords.
Ensure that area rugs have rubber backs.
Mark the edges of the doorway to the house with tape.
The Correct Answer is C
A. Wearing well-fitted shoes at home helps prevent slips and falls.
B. Placing throw rugs over electrical cords increases the risk of tripping.
C. Area rugs with rubber backs prevent slipping, reducing the risk of falls in a postoperative client.
D. Marking doorways with tape is not necessary for a client after knee replacement and may be more applicable for clients with visual impairments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Flumazenil is the antidote for benzodiazepine overdose and should be administered to reverse the effects of diazepam.
B. Monitoring the IV site is important but not an immediate priority in this situation.
C. Seizure precautions are not the primary concern after benzodiazepine overdose.
D. Evaluating for suicidal behavior is important but comes after stabilizing the client.
Correct Answer is ["A","C","D","F"]
Explanation
A. Blood pressure. A blood pressure of 162/112 mm Hg is severely elevated and indicative of preeclampsia, a serious complication during pregnancy. Uncontrolled hypertension can lead to maternal and fetal complications, such as eclampsia, placental abruption, or fetal growth restriction.
B. Urine ketones. The absence of ketones in the urine is normal and does not indicate any prenatal complication. Ketones would typically be seen in cases of starvation, dehydration, or poorly controlled diabetes, which are not evident here.
C. Urine protein. The presence of 3+ protein in the urine is a key diagnostic marker for preeclampsia. This finding, combined with elevated blood pressure, signals potential damage to the kidneys, which is a hallmark of severe preeclampsia.
D. Report of headache. A severe headache unrelieved by acetaminophen is a concerning symptom of preeclampsia. It suggests potential central nervous system involvement, which could lead to complications like seizures if left untreated.
E. Respiratory rate. The client’s respiratory rate of 16/min is within the normal range and does not indicate any immediate concern related to her pregnancy or current condition.
F. Fetal activity. The client’s report of decreased fetal movement is concerning and may indicate fetal distress or compromised placental function. This finding requires prompt evaluation to ensure fetal well-being.
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