The client has returned from surgery following a below the knee amputation (BKA). The residual limb is covered with a compression dressing. Immediately upon return from surgery, the dressing is dry. Thirty minutes later, a small amount of bloody drainage is noted on the dressing. What should be the nurse's priority action at this time?

Change the dressing

Notify the physician

Lower the head of the bed

Mark the area of drainage, time and date

Answer and Explanation

The Correct Answer is D

A.   While it is important to maintain a clean and dry dressing, changing it immediately may not be necessary at this stage. The small amount of bloody drainage could be a normal postoperative finding, and changing the dressing could disturb the surgical site.
B.   While it is important to keep the physician informed of any changes, in this case, a small amount of bloody drainage may not warrant immediate notification unless it becomes excessive or is accompanied by other concerning symptoms.
C.   Lowering the head of the bed might not directly address the situation. It may be more appropriate if the patient shows signs of hypotension or distress, but there is no indication that the drainage has caused such a concern at this moment.
D.   Marking the area of drainage allows for proper monitoring of the situation. It helps track whether the drainage increases, remains the same, or decreases over time. Documentation of the time and date also provides a clear record for the healthcare team regarding the postoperative course, which is essential for ongoing assessment.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. A serum fasting glucose level of 101 mg/dL indicates a mild elevation but is not significantly high enough to contraindicate the use of TMP-SMX. It does not directly relate to the medication’s safety.
B. A platelet count of 160,000 µL is within normal limits (normal range is typically 150,000-450,000 µL). This result does not indicate any contraindication for using TMP-SMX.

C. A serum creatinine level of 2.5 mg/dL indicates impaired kidney function (normal range is typically 0.6-1.2 mg/dL). TMP-SMX can be contraindicated in patients with significant renal impairment due to the potential for drug accumulation and toxicity, particularly affecting renal function.
D. A hemoglobin level of 13.6 g/dL is within normal limits (normal range is approximately 13.5-17.5 g/dL for males and 12.0-15.5 g/dL for females). This result does not indicate a contraindication for using TMP- SMX.

A. Test a sample of urine for the presence of occult blood B. Check the client's weight C. Instruct the client to increase his water intake D. Review results of liver function studies

Correct Answer is D

Explanation

A. While testing for occult blood can help rule out hematuria (blood in the urine), it’s not the immediate priority. Dark urine could be related to several factors, including dehydration or changes in liver function, making this not the best first step.
B. While monitoring weight is important, it doesn't directly address the issue of dark urine. Weight changes might indicate fluid retention or loss but are not as immediately relevant to the urine color change.
C. Increasing water intake can help dilute the urine and may help with hydration. However, before suggesting this, it's important to understand the underlying cause of the urine change.
D. Glipizide and other sulfonylureas can affect liver function, and dark urine can indicate potential liver issues, such as bilirubinuria (bilirubin in the urine). Reviewing liver function studies would provide critical information to assess if the change in urine color is related to liver dysfunction or other serious issues.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly admitted client has been prescribed sulfamethoxazole/trimethoprim. The nurse understands that this medication is contraindicated based on which lab result?

Correct Answer is C

Explanation

The client who has been taking glipizide for 6 months reports to the nurse that his urine has become darker since starting the medication. What is the nurse's first action?

Correct Answer is D

Explanation

The nurse administers 10 units of insulin lispro to a client at 0630 and anticipates that the client must have breakfast by:

The client is receiving a trimethoprim-sulfamethoxazole. What information should the nurse include in the teaching about this medication?

A nurse is teaching a client with diabetes mellitus about chronic complications associated with the disease. Which information should be included in the teaching?

What factors in the history of a client with schizoaffective disorders puts the client at higher risk for type 2 diabetes? (SELECT ALL THAT APPLY)

A physician orders Lithium 5 grams/day is three divided doses PO for a client with bipolar disorder. The medication is supplied 400 mg/5 mL. How much will the nurse administer per dose? (Round the answer to the nearest tenth Use a leading zero if it applies. Do not use a trailing zero.)

At 1630 a Type I diabetic client's blood glucose level is 50 mg/dl. The client is alert; however, dinner will not be served until 1715. The nurse's initial action should be to:

The nurse is teaching an adult client with Type 1 diabetes that a primary cause of the development of diabetic ketoacidosis (DKA) is:

The nurse must give 25 micrograms of fentanyl IVP X 1 dose. Fentanyl is available in an ampule 100 micrograms per 2mL. How many mL will the nurse give for the correct dose? round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.