Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with the care of a client who is 6 hr postoperative following a right total knee arthroplasty. Which of the following actions should the nurse take?
A. Maintain the head of the client's bed in high-Fowler's position.
B. Remove the client's dressing when it becomes saturated.
C. Check the client's pedal pulses every hour.
A nurse assisting with the care of a client who is 6 hours postoperative following a right total knee arthroplasty should check the client's pedal pulses every hour. This is important to assess the adequacy of blood flow and tissue perfusion to the extremity. It is also important to monitor the client's pain level, administer pain medication as ordered, and encourage the client to perform exercises as appropriate. The head of the client's bed should be maintained in a semi-Fowler's position to promote optimal respiratory function, and the client's dressing should be changed only as needed and with sterile technique. An abductor wedge is not typically used following knee arthroplasty surgery.
D. Place an abductor wedge under the client's right knee.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
A nurse assisting with the care of a client who is 6 hours postoperative following a right total knee arthroplasty should check the client's pedal pulses every hour. This is important to assess the adequacy of blood flow and tissue perfusion to the extremity.
It is also important to monitor the client's pain level, administer pain medication as ordered, and encourage the client to perform exercises as appropriate.
The head of the client's bed should be maintained in a semi-Fowler's position to promote optimal respiratory function, and the client's dressing should be changed only as needed and with sterile technique.
An abductor wedge is not typically used following knee arthroplasty surgery.
Similar Questions
A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching?
A. Assume responsibility for making the client's decisions.
B. Maintain a verbal no-harm contract with the client.
C. Limit the client's social interactions.
D. Encourage the client to be assertive.
Encouraging the client to be assertive is an important aspect of managing dependent personality disorder. It helps the client develop self-confidence, make independent decisions, and advocate for their own needs. Empowering the client to express their opinions and assert their boundaries can contribute to their personal growth and reduce their reliance on others.
Full Explanation
Encouraging the client to be assertive is an important aspect of managing dependent personality disorder. It helps the client develop self-confidence, make independent decisions, and advocate for their own needs.
Empowering the client to express their opinions and assert their boundaries can contribute to their personal growth and reduce their reliance on others.
A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?
A. Nursing care plan
A nursing care plan is a document that outlines the client's nursing diagnoses, goals, interventions, and evaluations. It is not the appropriate place to document a medication error or incident.
B. Incident report
An incident report is formal documentation used to report any unexpected or adverse events that occur during the course of patient care. It provides a record of the incident and helps identify areas for improvement in patient safety and quality of care. The incident report should include details about the error, the potential impact on the client, actions taken to address the error, and any necessary follow-up.
C. Provider's progress notes
The provider's progress notes are documentation made by the healthcare provider, typically documenting their assessments, diagnoses, treatment plans, and progress of the client. A medication error made by the nurse should not be documented in the provider's progress notes.
D. Controlled substance inventory record
The controlled substance inventory record is a record used to track the dispensing and administration of controlled substances. While it is important to maintain accurate records of controlled substances, documenting a medication error in this record is not the appropriate place as it is primarily used for inventory management purposes
Full Explanation
An incident report is formal documentation used to report any unexpected or adverse events that occur during the course of patient care. It provides a record of the incident and helps identify areas for improvement in patient safety and quality of care. The incident report should include details about the error, the potential impact on the client, actions taken to address the error, and any necessary follow-up.
A nursing care plan is a document that outlines the client's nursing diagnoses, goals, interventions, and evaluations. It is not the appropriate place to document a medication error or incident.
The provider's progress notes are documentation made by the healthcare provider, typically documenting their assessments, diagnoses, treatment plans, and progress of the client. A medication error made by the nurse should not be documented in the provider's progress notes.
The controlled substance inventory record is a record used to track the dispensing and administration of controlled substances. While it is important to maintain accurate records of controlled substances, documenting a medication error in this record is not the appropriate place as it is primarily used for inventory management purposes
A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?
A. Corn
B. Oranges
C. Grapes
Grapes are round and can easily get stuck in a child's throat, leading to choking. The other foods listed (corn, oranges, and potatoes) are less likely to cause choking because they can be cut into smaller pieces or are less likely to get stuck in a child's airway.
D. Potatoes
Full Explanation
Grapes are round and can easily get stuck in a child's throat, leading to choking. The other foods listed (corn, oranges, and potatoes) are less likely to cause choking because they can be cut into smaller pieces or are less likely to get stuck in a child's airway.