EXAM
Postoperative Teaching for Total Knee Arthroplasty
✅ Correct Answer: Flex the foot every hour when awake.
Rationale: Prevents thromboembolism and promotes venous return.
Closed-Chest Drainage System for Pneumothorax
✅ Correct Answer: Bubbling in the water seal chamber has ceased.
Rationale: Indicates lung re-expansion.
Warfarin Therapy for Atrial Fibrillation
✅ Correct Answer: INR 2.5
Rationale: Therapeutic range for atrial fibrillation is INR 2–3.
Stage 1 Pressure Injury Care
✅ Correct Answer: Change position every hour.
Rationale: Reduces pressure on bony prominences.
,Post-Hemodialysis Assessment
✅ Correct Answer: Restlessness
Rationale: May indicate disequilibrium syndrome (risk of seizures).
Post-Total Hip Arthroplasty Urinary Retention
✅ Correct Answer: Scan the bladder with a portable ultrasound.
Rationale: Assess bladder volume before intervention.
Health Risk for African American Clients
✅ Correct Answer: Hypertension
Rationale: Higher prevalence in African American populations.
Diabetic Ketoacidosis (DKA) Improvement
✅ Correct Answer: Glucose 272 mg/dL
Rationale: Glucose <300 mg/dL indicates improvement.
Post-Extubation Complication
✅ Correct Answer: Stridor
Rationale: Indicates airway obstruction (requires immediate action).
, Nephrostomy Tube Complication
✅ Correct Answer: The client reports back pain.
Rationale: May indicate tube dislodgement or blockage.
TB Precautions
✅ Correct Answer: Airborne
Rationale: Required for TB due to airborne transmission.
Radiation Implant Safety
✅ Correct Answer: Keep a lead-lined container in the client's room.
Rationale: For safe disposal if implant dislodges.
Post-Thyroidectomy Complication
✅ Correct Answer: Temperature 38.9° C (102° F)
Rationale: May indicate thyroid storm (life-threatening).
HIV/AIDS Infection Prevention
✅ Correct Answer: "I will no longer floss my teeth."
Rationale: Reduces risk of gum injury/infection.