The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?

Correct Answer: B

Rationale: In teaching a client about postoperative care following a total knee arthroplasty, the nurse must prioritize the instruction to use continuous passive motion (CPM) therapy to maintain joint mobility. This is crucial because CPM helps prevent joint stiffness, promotes circulation, and aids in the healing process by reducing the risk of complications such as blood clots and contractures. Option A, beginning ambulation as soon as possible, is important in the postoperative period to prevent complications like deep vein thrombosis, but CPM takes precedence in maintaining joint function. Option C, avoiding putting weight on the affected leg, is essential initially to prevent strain on the surgical site, but gentle movement with CPM is beneficial for recovery. Option D, applying ice packs to reduce pain and swelling, is helpful for acute postoperative pain management, but it is not as crucial for long-term joint mobility and function as CPM therapy. In an educational context, emphasizing the importance of CPM therapy in postoperative knee arthroplasty care helps students understand the rationale behind maintaining joint mobility and preventing complications, leading to improved patient outcomes and recovery.

Correct Answer: B

Rationale: In this scenario, the most appropriate action for the nurse to take first when a client receiving TPN reports nausea and dizziness is to check the client's vital signs and blood pressure (Option B). Checking the client's vital signs and blood pressure is crucial to assess the client's current physiological status and to determine if the symptoms of nausea and dizziness are related to any potential hemodynamic changes or complications. This immediate assessment can help the nurse identify any potential issues that require prompt intervention. Checking the client's blood glucose level (Option A) is important in clients receiving TPN, but in this situation of acute symptoms of nausea and dizziness, assessing vital signs takes priority. Decreasing the infusion rate of TPN (Option C) may be a necessary intervention, but it should be based on a comprehensive assessment that includes vital signs and blood pressure. Administering antiemetic medication as prescribed (Option D) may provide symptomatic relief, but it is essential to assess the client's vital signs first to ensure that the client's condition is stable and that the medication is safe to administer. In an educational context, it is critical for nurses to prioritize assessments based on the client's immediate needs and symptoms. Understanding the rationale behind each option helps nurses develop clinical reasoning skills to provide safe and effective patient care.

Correct Answer: C

Rationale: The correct answer is C) This medication helps improve cognitive function. Explanation: Donepezil is a cholinesterase inhibitor used to treat symptoms of Alzheimer's disease by increasing the levels of acetylcholine in the brain, which can help improve cognitive function, memory, and behavior. It does not cure Alzheimer's disease but can slow down the progression of symptoms and improve quality of life. Why the other options are wrong: A) Take the medication at bedtime for best results: The timing of medication administration is not the most important teaching point regarding donepezil. It is typically administered once daily in the morning, with or without food. B) Report any unusual changes in behavior: While important, this teaching point is more about monitoring for side effects or worsening symptoms rather than the primary purpose of the medication. D) This medication is a cure for Alzheimer's disease: This statement is incorrect. Donepezil does not cure Alzheimer's disease but rather manages symptoms and may slow down disease progression. Educational context: It is crucial for healthcare providers to educate patients and their families about the purpose and expected outcomes of medications like donepezil. Understanding the role of the medication in managing Alzheimer's disease can help set realistic expectations and improve adherence to treatment plans. Patients should be informed about the benefits and limitations of donepezil to make informed decisions about their care.

Correct Answer: D

Rationale: In the context of a client with a suspected pulmonary embolism (PE), the nurse's priority intervention should be to prepare the client for a CT scan (Option D). A CT scan is the gold standard diagnostic test for confirming the presence of a pulmonary embolism. Timely diagnosis is crucial in initiating appropriate treatment and preventing potential complications such as cardiopulmonary collapse. Administering anticoagulant therapy (Option A) is a common treatment for PE, but it should not be initiated without a confirmed diagnosis. Elevating the head of the bed (Option B) is important for optimizing respiratory function in patients with respiratory distress, but it is not the priority over confirming the diagnosis. Checking the client's oxygen saturation (Option C) is important for assessing respiratory status, but it does not address the immediate need for diagnostic confirmation in a suspected PE case. In an educational context, this question highlights the importance of prioritizing interventions based on the urgency of the situation. It reinforces the significance of diagnostic tests in guiding appropriate treatment decisions and emphasizes the critical role of nurses in advocating for timely and accurate diagnostic procedures to ensure optimal patient outcomes.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Report any unusual bleeding or bruising. Rationale: 1. **Correct Answer Explanation (C)**: Enoxaparin is an anticoagulant medication used to treat and prevent blood clots like deep vein thrombosis. One of the main side effects of anticoagulants is the risk of bleeding. Therefore, it is crucial for the nurse to educate the client to report any signs of unusual bleeding or bruising promptly. This teaching is essential for the client's safety and to prevent complications associated with anticoagulant therapy. 2. **Incorrect Answer Explanation**: - A) Rotate injection sites to avoid bruising: While rotating injection sites is a good practice for some medications, it is not the priority teaching point for a client on enoxaparin. The risk of bleeding and bruising is more critical than injection site rotation. - B) Administer the injection in the abdomen only: While enoxaparin is typically administered in the abdomen, this option does not address the crucial aspect of monitoring for bleeding or bruising. - D) Avoid contact sports to prevent injury: While it is generally advisable to avoid contact sports when on anticoagulant therapy, this option does not address the immediate need to monitor for potential side effects like bleeding. 3. **Educational Context**: Understanding the importance of patient education in medication management is critical for nurses. In the case of anticoagulant therapy, teaching patients about potential side effects like bleeding and bruising is essential for early detection and prevention of complications. Nurses play a crucial role in empowering patients to manage their conditions effectively through education and support. By emphasizing the need to report any unusual bleeding or bruising, the nurse ensures that the client is informed about a critical aspect of their medication regimen, promoting patient safety and optimal outcomes.