On the second postoperative day after a right total knee replacement (TKR), the client's right calf is twice the size of her left calf. What is the nurse's best first action?
A. Elevate the client's knees.
B. Massage the client's right calf.
C. Assess her rate, depth, and ease of respiration.
D. Measure the circumferences of both lower extremities.
D
A common complication after TKR is the formation of a thrombus below the surgical site. This complication can lead to a pulmonary embolus and can be life threatening. Before notifying the surgeon or the emergency team, assess the client's pulmonary status to determine if she has any manifestations of an embolus.
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Which outcome is most realistic and appropriate in planning care for any newly diagnosed client with anxiety?
a. Plans coping strategies for anxious situations b. Discusses the reasons for episodes with significant others c. Establishes two new social relationships d. Verbalizes that he is episode free
During the nurse's assessment of a female patient, the patient reveals that she experienced sexual abuse when she was a young woman. What is the nurse's most appropriate response to this disclosure?
A) Reassure her that this information will be kept a secret. B) Begin the process of intensive psychotherapy. C) Encourage the patient to phone 911. D) Facilitate appropriate resources and referrals.
A new admission to the labor and delivery unit asks whether she can have something to eat or drink. The nurse's best response is:
a. "Certainly. I will order you a light meal." b. "All women in labor are kept NPO until delivery." c. "If you drink a lot of liquids, you will not have to have an IV." d. "Let's check your orders. You may be able to have ice chips and liquids."
Which of the following factors does not affect personal hygiene practices?
A) Culture B) Income level C) Health state D) Gender