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","D"]

Explanation

Choice A reason: Checking the client's current fingerstick blood glucose is important to determine if the confusion and weakness are due to hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Choice B reason: Obtaining blood pressure and heart rate is useful for a general assessment but is secondary to assessing blood glucose levels in this scenario.

Choice C reason: Administering a PRN dose of regular insulin is not appropriate without first determining the client's blood glucose level. If the client is hypoglycemic, insulin could worsen the condition.

Choice D reason: Giving the client 4 ounces (120 mL) of orange juice is a quick way to raise blood sugar levels if the client is hypoglycemic.

Choice E reason: Providing diet carbonated soda is not effective for treating hypoglycemia because it does not contain sugar to raise blood glucose levels.

A. Research the religion on different social media platforms. B. Consult with a nurse who shares the same religious beliefs. C. Explain that every client will receive the same high level of care. D. Ask the client about individual care preferences.

Correct Answer is D

Explanation

Choice A reason: Researching the religion on social media is not a reliable or appropriate method for understanding individual care needs.

Choice B reason: Consulting with a nurse who shares the same religious beliefs may provide insight but does not address the specific concerns of the client.

Choice C reason: Explaining that every client receives the same high level of care does not address the client's individual religious needs and concerns.

Choice D reason: Asking the client about individual care preferences ensures that the nurse understands and respects the client's specific religious beliefs and practices.

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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 newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

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

Explanation

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

Correct Answer is D

Explanation

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

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.

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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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A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome should the nurse include in the plan of care for this client?

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