Which priority intervention should the day surgery nurse implement for a client who has had right knee arthroscopy?

Correct Answer: C

Rationale: The correct answer is C: Check the client's pulses distally and assess the toes. This is the priority intervention because it assesses neurovascular status post-arthroscopy, detecting any potential complications like impaired circulation. Checking pulses and toe assessment are crucial to prevent ischemia and ensure proper blood flow to the extremity. Encouraging range-of-motion exercises (A) is important but not the priority immediately post-surgery. Monitoring urine output and color (B) is important for hydration status but not as critical as neurovascular assessment. Monitoring vital signs (D) is also important but does not specifically address the risk of impaired circulation post-arthroscopy.

Correct Answer: B

Rationale: The correct answer is B because participation in self-care activities indicates effective pain management and adaptation to pain. Engaging in self-care activities suggests that the client is able to maintain independence despite the pain, which is a positive outcome. Choices A, C, and D are incorrect. A decrease in medication use may not always be appropriate for acute pain management. Relaxation techniques can help manage pain but may not be the primary expected outcome. Repeating instructions about medications does not directly relate to the expected outcome of managing acute pain.

Correct Answer: C

Rationale: The correct answer is C: Chronic exposure to loud noises. Prolonged exposure to loud noises can damage the sensitive structures in the inner ear leading to hearing loss. The nurse should discuss this risk factor with the client to raise awareness on the importance of protecting their hearing. Incorrect Choices: A: Multiple piercings in the auricle - Piercings do not directly cause hearing loss. B: Use of nephrotoxic medications - Nephrotoxic medications can damage the kidneys, not the ears. D: Taking oral antihistamines daily - Antihistamines are not known to cause hearing loss.

Correct Answer: C

Rationale: The correct answer is C because assessing for visual acuity and proprioceptive deficits is essential in managing a client with vertigo to identify potential factors contributing to impaired balance. Visual acuity helps determine if vision issues are exacerbating vertigo symptoms, while proprioceptive deficits affect body awareness and balance. By assessing these factors, the nurse can tailor interventions to address specific needs, such as recommending corrective measures for vision problems or implementing balance exercises. A: Providing information about vertigo is important but does not directly address the specific issue of assessing visual acuity and proprioceptive deficits. B: Assessing for diversional activities is important for overall client well-being but does not directly address the balance issues related to vertigo. D: Referring the client to a support group and counseling may be beneficial for emotional support but does not directly address the physical factors contributing to impaired balance.

Correct Answer: B

Rationale: The correct answer is B: Ask the client if there is an advance directive. This is important because it ensures that the client's wishes regarding their medical care are known and followed, especially in the case of a serious illness like pancreatic cancer. Discussing food preferences (A) and insurance/Medicare reimbursement (C) are important but not as critical initially. Instructing the client to eat as much as possible (D) may not be appropriate for a client with pancreatic cancer as they may have dietary restrictions.