1. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the
following instructions should the nurse include?
a. Flex the foot every hour when awake.
b. Place a pillow un
...
1. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the
following 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 for
thromboembolism and promote venous return.
2. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of
the following findings is an indication of lung re-expansion?
a. The chest tube is draining serosanguineous fluid at 65 mL/hr.
b. The client tolerates gentle milking of the tubing.
c. Bubbling in the water seal chamber has ceased.
d. There is tidaling in the water seal chamber.
Bubbling in the water seal chamber ceases when the lung re-expands.
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?
a. INR 1
b. INR 2.5
c. aPTT 45 seconds
d. aPTT 90 seconds
Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or
pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must
be monitored to ensure the anticoagulation is within the therapeutic range and prevent
hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation).
An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial
fibrillation.
4. A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater
trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?
a. Clean the wound daily with an antiseptic
CONTINUED........
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