Nokea
A patient is 1 day postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Administer aspirin for pain management.
- B. Keep the affected leg in a dependent position.
- C. Flex the affected knee for 2 to 3 minutes every hour.
- D. Apply ice packs to the affected knee.
Correct Answer: D
Rationale: The correct action for a client 1 day postoperative following a total knee arthroplasty is to apply ice packs to the affected knee. Ice packs help reduce swelling and pain in such clients. Administering aspirin is contraindicated due to the risk of bleeding postoperatively. Keeping the affected leg in a dependent position can impair circulation and increase the risk of complications. Flexing the affected knee for extended periods can strain the surgical site and hinder the healing process.
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A healthcare professional is preparing to administer enoxaparin to a client. Which of the following actions should the healthcare professional take?
- A. Administer the medication intramuscularly.
- B. Inject the medication into the lateral abdominal wall.
- C. Massage the injection site after administration.
- D. Discard the prefilled syringe after expelling the air bubble.
Correct Answer: B
Rationale: The correct answer is to inject the medication into the lateral abdominal wall when administering enoxaparin. This is the recommended technique to ensure proper absorption and prevent tissue damage. Choice A is incorrect because enoxaparin should be administered subcutaneously, not intramuscularly. Choice C is incorrect as massaging the injection site after administration is not recommended, as it can cause bruising and discomfort. Choice D is incorrect because the prefilled syringe should not be discarded after expelling the air bubble; it should be used for the injection.
A nurse is assessing a client who is 4 hours postoperative following a total hip arthroplasty. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 118/76 mm Hg
- B. Heart rate of 88/min
- C. Urinary output of 30 mL/hr
- D. Hematocrit 42%
Correct Answer: B
Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.
A nurse is planning care for a client who has a new diagnosis of heart failure. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1,500 mL per day.
- B. Encourage the client to walk every 2 hours.
- C. Monitor the client's weight daily.
- D. Administer oxygen via nasal cannula at 2 L/min.
Correct Answer: C
Rationale: The correct intervention the nurse should include in the plan of care for a client with heart failure is to monitor the client's weight daily. Daily weight monitoring is essential to assess fluid balance and detect any signs of worsening heart failure. Limiting fluid intake to 1,500 mL per day (Choice A) may be appropriate in some cases, but it is not the initial priority for this client. Encouraging the client to walk every 2 hours (Choice B) is generally beneficial for mobility but may not be directly related to managing heart failure. Administering oxygen via nasal cannula at 2 L/min (Choice D) is a supportive measure for hypoxia but does not directly address heart failure management.
A client who is at 30 weeks of gestation and is scheduled for a nonstress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should avoid drinking fluids during the test.
- B. I will need to drink a sugar solution before the test.
- C. This test will monitor how my baby is responding to contractions.
- D. This test will assess for fetal lung maturity.
Correct Answer: B
Rationale: The correct answer is B because the client should drink a sugar solution for a glucose challenge test, which is part of the nonstress test protocol during pregnancy. Choice A is incorrect because adequate hydration is generally recommended before the test. Choice C is incorrect as the nonstress test monitors the baby's heart rate in response to its own movements, not contractions. Choice D is incorrect as the nonstress test does not assess fetal lung maturity.
A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 20/min
- B. Oxygen saturation of 93%
- C. Pain level of 2 on a scale of 0 to 10
- D. Blood pressure of 110/70 mm Hg
Correct Answer: D
Rationale: The correct answer is D because a blood pressure drop or other signs of morphine overdose should be reported, especially when using a PCA pump. Choices A, B, and C are within normal limits and do not indicate an immediate concern related to morphine administration.