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","B","C","D","E"]

Explanation

Choice A reason: Orthostatic hypotension is a common issue in PD and requires interventions to prevent falls.

Choice B reason: Stooped posture is characteristic of PD and affects mobility and balance.

Choice C reason: Bradykinesia (slowness of movement) is a hallmark of PD and impacts daily activities and mobility.

Choice D reason: Muscular rigidity is a key symptom of PD and affects the client's ability to move freely.

Choice E reason: A shuffling, propulsive gait is typical in PD and requires interventions to ensure safety and improve mobility.

A. Observe the appearance of the client's urine. B. Measure the girth of the client's lower abdomen. C. Auscultate an area six inches below the umbilicus. D. Palpate the area above the pubic symphysis.

Correct Answer is D

Explanation

Choice A reason: Observing the appearance of urine can provide information but is not the most direct assessment for urinary retention.

Choice B reason: Measuring the girth of the lower abdomen is not a specific assessment for urinary retention.

Choice C reason: Auscultation is not a reliable method for assessing urinary retention.

Choice D reason: Palpating above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

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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

A client with Parkinson's disease (PD) is admitted to the medical surgical unit and the nurse assesses the client's mobility needs. Which finding(s) indicate the need to plan interventions related to the client's mobility? Select all that apply.

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

Explanation

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is D

Explanation

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to a healthcare provider for evaluation of thyroid functioning?

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

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?

The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?

A client with pancreatitis reports severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?