Nokea
The nurse assesses the client 4 hours following a left TKR. The client has a knee immobilizer in place with medial and lateral packs that are warm. An autotransfusion wound drainage system has 350 mL collected. The client has not voided since before surgery but does not express a need. Which interventions should the nurse plan to implement at this time? Select all that apply.
- A. Reinfuse the salvaged blood from the wound drainage system.
- B. Remove the immobilizer to place the knee in 90-degree flexion.
- C. Stand the client at the bedside to facilitate bladder emptying.
- D. Place the left leg in a continuous passive motion device (CPM).
- E. Replace the warm packs in the knee immobilizer with ice packs.
Correct Answer: A,E
Rationale: A. An autotransfusion drainage system is used in the immediate postoperative period if extensive bleeding is anticipated. Collected drainage can be reinfused up to 6 hours postoperative. E. Ice packs, used to reduce swelling and control bleeding, are replaced every 2 hours. If they have warmed, they need to be replaced.
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The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse's priority?
- A. Presence of bruising to the right elbow
- B. Pain level rating on a 0-10 scale
- C. Sensation and pulse of the right forearm
- D. Left-handed or right-handed
Correct Answer: C
Rationale: C. Impairment of the neurovascular system is a priority. The closed reduction could cause further damage, which would be noted distal to the injury. Sensation and pulses are part of a neurovascular assessment to an extremity.
Which client symptom indicates that the nurse should discontinue the medication and notify the physician even if the client's pain is unrelieved?
- A. Vomiting
- B. Dizziness
- C. Drowsiness
- D. Headache
Correct Answer: A
Rationale: Vomiting is a sign of colchicine toxicity, requiring immediate cessation.
Which assessment finding warrants immediate action by the nurse when a client is in Buck's traction?
- A. The traction weights are hanging above the floor.
- B. The leg is in line with the pull of the traction.
- C. The right is about is to be the two.
- D. The rope is in the groove of the traction pulley.
Correct Answer: A
Rationale: Traction weights must hang freely to maintain proper pull. If they are above the floor (e.g., resting on something), the traction is ineffective, requiring immediate correction to ensure proper alignment and healing.
Which level of participation should the nurse expect when assessing a 9-year-old who has mental retardation with an IQ level of 45?
- A. Able to communicate verbally only with two-letter words
- B. Able to read and comprehend simple written instructions
- C. Able to walk independently and perform a simple skill
- D. Able to perform tasks that require careful manual dexterity
Correct Answer: C
Rationale: An IQ of 45 indicates moderate intellectual disability, allowing independent walking and simple tasks.
The nurse is teaching the client with gout about a diet low in purines. Which of the following is lowest in purine?
- A. Roast chicken
- B. Beef liver
- C. Fried shrimp
- D. Scrambled eggs
Correct Answer: D
Rationale: Scrambled eggs are low in purines, suitable for a gout diet, unlike high-purine foods like liver and shrimp.