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: Understanding the reason for taking the aspirin is crucial because aspirin may be prescribed for various reasons, such as pain relief, anti-inflammatory purposes, or cardiovascular protection. Knowing the reason helps the nurse assess if ibuprofen is a suitable substitute or if additional interventions are needed.

Choice B reason: While the presence of gastric pain is important, it is secondary to understanding the underlying reason for aspirin use.

Choice C reason: Assessing the amount of pain control achieved with ibuprofen is important for managing the client's symptoms, but it is not the first priority.

Choice D reason: Knowing the dosage of ibuprofen taken is essential for determining if the client is taking an appropriate amount, but it comes after understanding the initial indication for aspirin use.

A. Bowl of oatmeal. B. Bacon slices. C. Raisin bran muffins. D. Cup of raspberries. E. Scrambled eggs.

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Oatmeal is high in fiber and helps soften stools, making it a good option for someone with hemorrhoids.

Choice B reason: Bacon slices are not high in fiber and are not recommended.

Choice C reason: Raisin bran muffins are high in fiber and beneficial for managing hemorrhoids.

Choice D reason: Raspberries are high in fiber and are a good choice for a high-fiber diet.

Choice E reason: Scrambled eggs do not contain fiber and are not particularly beneficial for increasing fiber intake.

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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 nurse is caring for a client who reports running out of aspirin one week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

Correct Answer is A

Explanation

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

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