The nurse is caring for a client who had right total knee replacement surgery 3 days ago. During the assessment, the nurse notes that the client's right lower leg is twice the size of the left. What is the nurse's priority intervention?
a. Elevate the client's right leg.
b. Apply antiembolism stockings.
c. Assess the client's respiratory status.
d. Check the client's pedal pulses.
C
A common complication after total knee replacement (TKR) is the formation of a thrombus be-low the surgical site. This complication can lead to a pulmonary embolus and can be life threat-ening. Before notifying the surgeon or the emergency team, assess the client's pulmonary status to determine whether he or she has any manifestations of an embolus. The client's leg may be elevated and pedal pulses palpated, but respiratory assessment must be done first. TED hose should not be applied to a leg with suspected deep vein thrombosis (DVT).
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The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
A) Maximize the patient's fluid intake. B) Provide total parenteral nutrition (TPN). C) Keep the patient's bed linens free of wrinkles. D) Provide the patient with snug clothing at all times.
When do unions seem to thrive?
A) When salaries do not keep pace with the economy B) When organizations are insensitive to the worker C) When there is an economic downturn D) When jobs are scarce
Don, age 62, calls to complain of a severe headache. Which of his following statements most concerns you?
A. "It hurts when I turn my head a specific way." B. "It's the worst headache I've ever had." C. "Nothing I do seems to help this constant ache." D. "I'm so worried. Can you do a CT scan?"
T.B. is a 65-year-old retiree who is admitted to your unit from the emergency department (Ed). On arrival,
you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid back as a deep, sharp, boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but "none as bad as this." He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fried fish and chips at a fast-food restaurant earlier today. He is not happy to be in the hospital and is grumpy that his daughter insisted on taking him to the Ed for evaluation. After orienting him to the room, you perform your physical assessment. The findings are as follows: He is awake, alert, and oriented× 3, and he moves all extremities well. He is restless, constantly shifting his position, and complains of fatigue. Breath sounds are clear to auscultation. Heart sounds are clear and crisp, with no murmur or rub noted and with a regular rate and rhythm. Abdomen is flat, slightly rigid, and very tender to palpation throughout, especially in the RUQ; bowel sounds are present. He reports having light-colored stools for 1 week. The patient voids dark amber urine but denies dysuria. skin and sclera are jaundiced. Admission vital signs are blood pressure 164/100, pulse of 132 beats/min, respiration 26 breaths/min, temperature of 100° F (37.8° C), spo2 96% on 2 L of oxygen by nasal cannula. What structures are located in the RUQ of the abdomen? What will be an ideal response?