A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make?
Place a towel on the floor outside of the shower.
Ensure that all area rugs are rubber-backed.
Wear slippers with cloth soles.
Place a handrail in the entryway of the house.
The Correct Answer is B
A. A towel on the floor outside of the shower could be a tripping hazard.
B. This prevents slipping and falls, which is crucial for someone recovering from knee surgery.
C. Slippers with non-slip soles would be a safer choice to prevent falls.
D. While handrails are helpful for mobility and safety, this recommendation does not address the immediate postoperative care needs of the client following knee surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","G","H"]
Explanation
A. Contact precautions are not indicated based on the assessment findings provided.
Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.
B. The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.
C. a deep tendon reflex (DTR) grade of 3+ indicates a brisker than average response, which could be normal or potentially indicative of neurological hyperactivity. In such cases, creating a calming environment, which may include dimmed lighting, could potentially help in reducing stimuli that might exacerbate neurological excitability.
D. The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.
E. Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.
F. Preeclampsia can have adverse effects on fetal well-being, including intrauterine growth restriction and placental insufficiency. However, an external fetal monitoring provides a more accurate assessment of fetal heart rate patterns and allows for closer monitoring of fetal status in cases of maternal hypertension.
G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.
H. Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.
Correct Answer is C
Explanation
A. Chorioamnionitis, an infection of the fetal membranes, can lead to fetal tachycardia and no bradycardia
B. Fetal anemia might present with tachycardia rather than bradycardia.
C. Maternal hypoglycemia can cause fetal bradycardia since when a mother experiences hypoglycemia, it can result in inadequate blood glucose levels that are crucial for both her and the fetus. This condition can impair the oxygen and nutrient delivery to the fetus, as the mother's body prioritizes her own metabolic needs. Consequently, the fetal heart rate may slow down as a response to the stress of reduced energy supply.
D. Maternal fever is associated with fetal tachycardia rather than bradycardia.
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