1.A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of thefollowing instructions should the nurse include?a.Flex the foot every hour when awake.b.Place a pillow under the knee when lying in bed.c.Lower the leg when sitting in a chair.d.Ensure the leg is abducted when resting in bed.The nurse should instruct the client to flex the foot every hour to reduce the risk forthromboembolism and promote venous return.
2.A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which ofthe following findings is an indication of lung re-expansion?
3.A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation.Which of the following values should the nurse identify as a desired outcome for this therapy?
4.A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greatertrochanter of his left hip. Which of the following instructions should the nurse include in the teaching?
5.A nurse is assessing a client following the completion of hemodialysis. Which of the following findings isthe nurse’s priority to report to the provider?a.Temperature 37.2° C (99° F)b.Blood pressure 100/70 mm Hgc.Weight lossd.RestlessnessUsing the urgent vs. nonurgent approach to client care, the nurse should determine that thepriority finding to report to the provider is restlessness, which can be an indication the client isexperiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removalof electrolytes from the client's blood and can lead to dysrhythmias or seizures. Othermanifestations include nausea, vomiting, fatigue, and headache.
Step 1: What is the unit of measurement the nurse should calculate? Calories
Step 2: What is the volume the nurse should infuse? 60 mL/hr x 12 hr = 720 mL
Step 3: What is the total infusion time? 12 hrs
Step 4: Should the nurse convert the units of measurement? No
Step 5: Set up an equation and solve for x.
720 mL x 1.2 cal/mL = calories
x = 864 cal
Step 6: Round if necessary.
Step 7: Reassess to determine if the amount to administer makes sense.
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