HESI RN Exit Proctored Exam
The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?
Explanation & Rationale
A. Withholding the next dose of low molecular weight heparin is not indicated unless there is active bleeding. B. Monitoring the white blood cell count is not the immediate priority in this situation. Wound drainage is more relevant. C. The continuous passive motion device is used for promoting mobility, but it is not related to the issue of excessive drainage. D. Saturated dressing with serosanguineous drainage after surgery can be normal initially, but ensuring the wound drainage device is functioning correctly is crucial to prevent complications like hematoma or excessive swelling.
🔒 Submit your answer to reveal
Your Progress
Correct0
Incorrect0
Skipped0
Accuracy0%