Nokea
A client was admitted to the surgical unit after right total knee arthroscopy performed 2 hours earlier. Which surgeon's prescription requires clarification?
- A. Maintain right knee in a slightly flexed position.
- B. Implement patient-controlled analgesia (PCA) per my protocol.
- C. Place sequential compression devices on both legs while on bed rest.
- D. Notify physical therapy to begin isometric quadriceps exercises on the day following surgery.
Correct Answer: A
Rationale: The knee is immobilized by a compression dressing to keep the knee in extension immediately after the operation. The nurse should clarify a prescription to keep the knee slightly flexed. Pain control by use of patient-controlled analgesia, use of compression devices to reduce the risk of thromboembolism, and physical therapy to begin isometric quadriceps exercises are expected prescriptions after total knee arthroscopy surgery.
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A client with a history of osteoarthritis is prescribed ibuprofen. The nurse should instruct the client to take the medication:
- A. On an empty stomach to enhance absorption.
- B. With food to reduce gastrointestinal irritation.
- C. At bedtime to promote sleep.
- D. With a diuretic to reduce swelling.
Correct Answer: B
Rationale: Ibuprofen should be taken with food to minimize gastrointestinal irritation and reduce the risk of ulcers.
A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:
- A. Intermittent claudication.
- B. Dyspnea.
- C. Dependent edema.
- D. Crackles.
Correct Answer: C
Rationale: Dependent edema is a key sign of right-sided heart failure, as the heart fails to pump blood effectively, causing fluid backup in the extremities.
The nurse is assessing a client with a suspected perforated peptic ulcer. Which of the following findings is most indicative of this condition?
- A. Sudden severe abdominal pain.
- B. Chronic epigastric pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Sudden severe abdominal pain is a hallmark sign of a perforated peptic ulcer due to peritoneal irritation.
The nurse is teaching a client with a new diagnosis of epilepsy about medication adherence. Which of the following instructions is most important?
- A. Take the medication exactly as prescribed.
- B. Skip doses if you feel well.
- C. Double the dose if you miss one.
- D. Stop the medication if side effects occur.
Correct Answer: A
Rationale: Taking antiepileptic medication exactly as prescribed is critical to prevent seizures.
A client with a suspected stroke is admitted to the emergency department. What is the nurse's priority action?
- A. Administer aspirin as ordered.
- B. Assess neurological status.
- C. Prepare for a CT scan.
- D. Monitor blood pressure.
Correct Answer: B
Rationale: Assessing neurological status is the priority to establish a baseline and detect changes in a suspected stroke, guiding urgent interventions.