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    PN Comprehensive Predictor 2023 Proctored Exam

    A nurse is assisting with the care of a client who is 6 hr postoperative following a right total knee arthroplasty. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Check the client's pedal pulses every hour: Frequent assessment of distal circulation is crucial after a total knee arthroplasty to detect signs of compromised blood flow, such as thromboembolism or compartment syndrome. Monitoring pulses, skin color, and temperature helps identify early complications and prevent tissue damage. B. Maintain the head of the client's bed in high-Fowler's position: High-Fowler’s position is not recommended post-knee arthroplasty as it can increase strain on the surgical site and reduce venous return from the lower extremities. Keeping the leg elevated and the client in a semi-Fowler’s or supine position is safer. C. Remove the client's dressing when it becomes saturated: Dressings should only be removed or changed according to the provider’s protocol, typically by sterile technique. Premature removal can increase the risk of infection and disrupt the healing surgical site. D. Place an abductor wedge under the client's right knee: Abductor wedges are primarily used after hip replacement to maintain hip alignment, not knee arthroplasty. Placing one under the knee could cause discomfort or improper positioning. Proper knee alignment involves elevation and extension support.

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