Nokea
The nurse is caring for a client who is postoperative day 1 after a total knee replacement. Which of the following actions is the PRIORITY?
- A. Encourage the client to use the incentive spirometer.
- B. Administer pain medication as needed.
- C. Apply a continuous passive motion (CPM) machine.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Applying the CPM machine is the priority to prevent stiffness and promote joint mobility post-knee replacement. Options A, B, and D are important but secondary: incentive spirometry prevents pneumonia, pain management supports recovery, and dressing checks monitor bleeding.
You may also like to solve these questions
A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection.
The patient's preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment is to
- A. minimize the bacterial count in the mouth.
- B. soften the mucous membranes of the tongue before surgery.
- C. stimulate the microcirculation of the mouth.
- D. hydrate the tissues of the gums.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the procedure. (1) correct-destroys bacteria found in mouth, reduces the chance of infection (2) is not the action of hydrogen peroxide (3) circulation is unaffected by a mouth rinse (4) has slight drying effect on mucous membranes
During auscultation of the fetal heart rate during labor, the nurse assesses a rate of 59 beats per minute.
The FIRST action the nurse should take is
- A. turn the mother on her right side, increase the intravenous flow rate, and call the physician.
- B. turn the mother on her left side, administer oxygen by nasal cannula, and start an IV.
- C. call the physician, and make preparations for an immediate emergency cesarean section.
- D. position the mother in Trendelenburg's position, administer oxygen, and force fluids.
Correct Answer: B
Rationale: Strategy: 'FIRST' indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should be placed on left side to increase blood flow to the uterus (2) correct-persistent fetal bradycardia may indicate cord compression or separation of the placenta, but always indicates fetal distress, left side reduces compression of vena cava and aorta (3) should be done after positioning patient (4) this position is used only if there is cord prolapsed
The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which of the following statements by the client indicates a need for further teaching?
- A. I should exercise for 30 minutes most days.
- B. I should reduce my salt intake.
- C. I should avoid smoking.
- D. I should limit my coffee to one cup a day.
Correct Answer: D
Rationale: Limiting coffee to one cup a day is unnecessary, as moderate caffeine does not significantly affect blood pressure in most hypertensive patients. Options A, B, and C are correct: exercise, low-sodium diet, and smoking cessation reduce blood pressure.
The nurse is preparing a five-year-old child for surgery.
- A. What is the best action for the nurse when the informed consent for a five-year-old’s surgery is signed by the mother, and the parents are divorced with joint legal custody?
- B. Notify the physician.
- C. Inform surgery.
- D. Contact the father to obtain consent.
- E. Continue the child’s preoperative preparation.
Correct Answer: D
Rationale: In cases of joint legal custody, consent from either parent is sufficient for surgical procedures. Since the mother has signed the informed consent, no further action is needed, and the nurse should continue preoperative preparation. Notifying the physician, informing surgery, or contacting the father is unnecessary.
The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed?
- A. I have been very careful to wash my hands after I go to the bathroom.
- B. I have had to take Tylenol several times this week for this sinus infection I have.
- C. I have been very careful not to handle my child's toys or eating utensils.
- D. My husband has been preparing all of the meals since I've been sick.
Correct Answer: B
Rationale: Tylenol (acetaminophen) is hepatotoxic and should be avoided in hepatitis A, which impairs liver function, indicating a need for further teaching. Options A, C, and D show correct precautions to prevent oral-fecal transmission.