Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a client who is 6 hr postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's plan of care?
A. Apply warm, moist packs to the surgical site.
B. Place a pillow under the client's surgical knee
C. Use the continuous passive-motion machine intermittently.
Using the continuous passive-motion machine intermittently helps to prevent joint stiffness and promote circulation in the surgical leg. Applying warm, moist packs to the surgical site can increase inflammation and infection risk. Placing a pillow under the client's surgical knee can cause flexion contractures and impair healing. Massaging the lower leg in smooth, long strokes can dislodge a thrombus and cause a pulmonary embolism.
D. Massage the lower leg in smooth, long strokes.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is C.
Using the continuous passive-motion machine intermittently helps to prevent joint stiffness and promote circulation in the surgical leg. Applying warm, moist packs to the surgical site can increase inflammation and infection risk. Placing a pillow under the client's surgical knee can cause flexion contractures and impair healing. Massaging the lower leg in smooth, long strokes can dislodge a thrombus and cause a pulmonary embolism.
Similar Questions
A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?
A. Instruct the client to cough every 4 hr.
B. Encourage the client to ambulate to loosen secretions.
C. Maintain the client in high-Fowler's position.
The nurse should maintain the client in high-Fowler's position, which promotes lung expansion and reduces venous return to the heart. This can help alleviate dyspnea and improve oxygenation in clients with heart failure.
D. Increase the client's intake of oral fluids.
Full Explanation
The nurse should maintain the client in high-Fowler's position, which promotes lung expansion and reduces venous return to the heart.
This can help alleviate dyspnea and improve oxygenation in clients with heart failure.
A nurse is reviewing the medical record of a client who is taking acetaminophen to relieve headache pain.
Which of the following conditions in the client's history should the nurse identify as a contraindication?
A. Cystitis
B. Hepatitis C
Hepatitis C is a contraindication for taking acetaminophen because it can cause hepatotoxicity and liver failure in clients who have liver disease. Cystitis, hypotension, and diabetes mellitus are not contraindications for taking acetaminophen.
C. Hypotension
D. Diabetes mellitus
Full Explanation
The correct answer is B.
Hepatitis C is a contraindication for taking acetaminophen because it can cause hepatotoxicity and liver failure in clients who have liver disease. Cystitis, hypotension, and diabetes mellitus are not contraindications for taking acetaminophen.
A nurse is caring for a client who has wrist restraints in place. Which of the following findings indicates that the restraints are applied correctly?
A. The restraints are attached to the side rails of the client's bed.
The restraints should never be attached to the side rails of the bed. This can cause injury if the side rails are moved up or down. Instead, restraints should be attached to a part of the bed frame that does not move.
B. The nurse can insert three fingers under the secured restraint.
The nurse should be able to insert only two fingers under the secured restraint. If three fingers can be inserted, the restraint is too loose and may not effectively prevent the patient from harming themselves or others.
C. The restraints are secured with a quick-release knot.
Securing the restraints with a quick-release knot is correct because it allows for easy and rapid removal in case of an emergency.
D. The restraint's soft pad faces away from the client's skin.
The soft pad of the restraint should face the client’s skin to prevent skin irritation and injury. If the soft pad faces away from the skin, it can cause discomfort and potential harm.
Full Explanation
The correct answer is choice c. The restraints are secured with a quick-release knot.
Choice A rationale:
The restraints should never be attached to the side rails of the bed. This can cause injury if the side rails are moved up or down. Instead, restraints should be attached to a part of the bed frame that does not move.
Choice B rationale:
The nurse should be able to insert only two fingers under the secured restraint. If three fingers can be inserted, the restraint is too loose and may not effectively prevent the patient from harming themselves or others.
Choice C rationale:
Securing the restraints with a quick-release knot is correct because it allows for easy and rapid removal in case of an emergency.
Choice D rationale:
The soft pad of the restraint should face the client’s skin to prevent skin irritation and injury. If the soft pad faces away from the skin, it can cause discomfort and potential harm.