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 A

Explanation

Choice A reason: Completing ongoing focused assessments, particularly for a client with wrist restraints, requires the clinical judgment and skills of an RN.

Choice B reason: Supervising a newly hired graduate nurse is important but can also be done by the charge nurse or another experienced RN.

Choice C reason: Transporting a client to the radiology department can be done by a UAP or PN.

Choice D reason: Administering PRN oral analgesics can be delegated to a PN.

A. Attempt to comfort the client by agreeing with the delusions and ask open-ended questions. B. Present a personal perception of reality in a nonconfrontational manner. C. Disagree with the statement and set clear limits on talking about it. D. Immediately inform the healthcare provider that the client is experiencing a delusional episode.

Correct Answer is B

Explanation

Choice A reason: Attempting to comfort the client by agreeing with the delusions is not therapeutic and may reinforce the delusional beliefs.

Choice B reason: Presenting a personal perception of reality in a nonconfrontational manner helps the client recognize reality without creating conflict or distress.

Choice C reason: Disagreeing with the statement and setting clear limits may be perceived as confrontational and could increase the client's distress.

Choice D reason: Informing the healthcare provider is important but should not be the immediate action. Addressing the client's delusions therapeutically is the first priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Correct Answer is A

Explanation

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Correct Answer is B

Explanation

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

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A client presents to the emergency department (ED) reporting abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client?

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?

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?