The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?

Confirm that the continuous passive motion device is intact.

Withhold next scheduled dose of low molecular weight heparin.

Determine if the wound drainage device is functioning correctly.

Monitor the client's current white blood cell count (WBC).

Answer and Explanation

The Correct Answer is C

Choice A reason: Confirming the continuous passive motion device is intact is important but secondary to assessing the source of the drainage.

Choice B reason: Withholding the next dose of low molecular weight heparin should only be done based on a healthcare provider's order after assessing the situation.

Choice C reason: Determining if the wound drainage device is functioning correctly is essential to manage the excessive drainage and ensure that there is no blockage or malfunction.

Choice D reason: Monitoring the client's WBC count is important for detecting infection but is not the immediate action required for managing active drainage.

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Correct Answer is B

Explanation

Choice A reason: Exenatide should be administered within 60 minutes before the morning and evening meals, not within 30 minutes before or after a meal.

Choice B reason: Notifying the healthcare provider if abdominal pain occurs is important because exenatide can cause pancreatitis, and abdominal pain may be a symptom of this condition.

Choice C reason: Exenatide does not act in the same way as insulin. It is an incretin mimetic that enhances glucose-dependent insulin secretion, among other actions.

Choice D reason: There are precautions when taking exenatide with other medications, especially those that affect blood glucose levels, so this statement is incorrect.

A. Severe motor dysfunction determines the extent of successful habilitation. B. Continued development of the brain lesion determines the child's outcome. C. Brain damage with CP is not progressive but does have a variable course. D. CP is one of the most common permanent physical disabilities in children.

Correct Answer is C

Explanation

Choice A reason: Severe motor dysfunction does influence the extent of successful habilitation, but it does not fully answer the mother’s concern regarding the progression of CP. The focus should be on reassuring the mother about the non-progressive nature of CP.

Choice B reason: The development of the brain lesion is already established in CP and does not continue to develop; thus, it does not determine the child's future outcome. The brain lesion's presence from birth does not change over time.

Choice C reason: Brain damage associated with CP is non-progressive, meaning it does not worsen over time. However, the symptoms and functional impairments can vary and fluctuate, which might make it seem as though the condition is changing.

Choice D reason: While it’s true that CP is one of the most common permanent physical disabilities in children, it doesn’t provide specific information about the progression of the disease. The mother needs to understand that the brain damage itself is not progressive.

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The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

Correct Answer is B

Explanation

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Correct Answer is C

Explanation

The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

A client who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day IV in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?