Medical
Surgical
Proctored
Assessment
B
A
nurse
is
providing
postoperative
teaching
for
a
client
who
had
a
total
knee
arthroplasty.
Which
of
the
following
should
the
nurse
include?
A.
Flex
the
foot
q
hr
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.
-
ANSA.
Flex
the
foot
q
hr
when
awake.
The
nurse
should
instruct
the
client
to
flex
the
foot
every
hour
to
reduce
the
risk
for
thromboembolism
and
promote
venous
return.
B.
Avoid
placing
pillows
under
the
knee
to
prevent
flexion
contractures.
C.
Elevate
the
leg
when
sitting
in
a
chair
to
reduce
edema
and
pain.
D.
Keep
the
operative
leg
in
a
neutral
position
when
resting
in
the
bed
to
prevent
dislocation
of
the
knee.
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.
-
ANSC.
Bubbling
in
the
water
seal
chamber
has
ceased.
Bubbling
in
the
water
seal
chamber
ceases
when
the
lung
re-expands.
D.
The
presence
of
tidaling
in
the
water
seal
chamber
results
from
the
client's
inhalation
and
exhalation
and
is
NOT
indicative
of
lung
re-expansion.
A
nurse
is
assessing
a
client
following
the
completion
of
hemodialysis.
Which
of
the
following
findings
is
the
nurse's
priority
to
report
to
the
provider?
A.
Temperature
37.2
C
(99
F)
B.
BP
100/70 C.
Weight
loss
D.
Restlessness
-
ANSD.
Restlessness
Using
the
urgent
vs.
nonurgent
approach
to
client
care,
the
nurse
should
determine
that
the
priority
finding
to
report
to
the
provider
is
restlessness,
which
can
be
an
indication
the
client
is
experiencing
disequilibrium
syndrome.
Disequilibrium
syndrome
is
caused
by
the
rapid
removal
of
electrolytes
from
the
client's
blood
and
can
lead
to
dysrhythmias
or
seizures.
Other
manifestations
include
nausea,
vomiting,
fatigue,
and
headache.
A.
An
increased
temperature
is
an
expected
finding
for
a
client
who
has
just
completed
dialysis.
The
dialysis
machine
slightly
warms
the
bloods.
B.
A
decreased
in
BP
is
an
expected
finding
for
a
client
who
has
just
completed
dialysis.
The
decrease
is
a
result
of
the
removal
of
excess
fluid
from
the
client's
blood.
C.
This
is
an
expected
finding
after
dialysis.
A
nurse
is
caring
for
a
client
who
has
DKA.
Which
of
the
following
findings
should
indicate
to
the
nurse
that
the
client's
condition
is
improving?
A.
K+
3.5
mEq/L
B.
pH
7.28
C.
BG
272
mg/dL
D.
HCO3
14
mEq/L
-
ANSC.
BG
272
mg/dL
A
glucose
reading
<300
mg/dL
indicates
improvement
in
the
client's
status.
A.
A
K+
level
of
a
client
who
has
DKA
might
be
below,
at,
or
above
the
expected
range.
B.
This
is
an
expected
finding
and
does
not
indicate
improvement.
D.
This
is
an
expected
finding
and
does
not
indicate
improvement.
A
nurse
is
caring
for
a
client
who
had
a
nephrostomy
tube
inserted
12
hours
ago.
Which
of
the
following
findings
should
the
nurse
report
to
the
provider?
A.
The
client's
urinary
output
has
increased.
B.
The
client
reports
back
pain.
C.
The
client's
urine
color
is
red
tinged.
D.
The
client's
BUN
is
18
mg/dL.
-
ANSB.
The
client
reports
back
pain.
The
nurse
should
notify
the
provider
if
the
client
reports
back
pain,
which
can
indicate
that
the
nephrostomy
tube
is
dislodged
or
clogged.
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