A 68-year-old client who had a right Total Hip Arthroplasty (THA) is returning to the orthopedic surgeon's office for a 6-week follow-up visit. While in the hospital recovering from surgery, the client experienced a pulmonary embolism (PE), which was successfully treated.
Based on the nurse's brief assessment, which findings indicate that the client is improving or progressing?
Performing activities of daily living (ADLs) without assistance.
Recent weight loss of 27 lbs.
Walking independently with the use of a cane.
Right arm is badly bruised and discolored.
Left hip is becoming more painful with movement.
No new reports of shortness of breath or chest pain.
Oxygen saturation (SpO2) of 95
Hip incision is healing with a visible hairline scar.
Correct Answer : A,C,F,G,H
Evaluating post surgical and post pulmonary embolism recovery requires assessing functional mobility, respiratory stability, and wound healing. Knowledge of normal rehabilitation milestones and the resolution of thromboembolic symptoms is necessary to determine if the client is meeting expected outcomes.
Choice A rationale
Independent performance of activities of daily living indicates restored functional capacity and successful rehabilitation after surgery. It demonstrates that the client has regained sufficient strength and coordination to manage self care tasks without exhausting their cardiovascular reserves.
Choice B rationale
Unintentional weight loss of 27 lbs within six weeks is an abnormal finding that suggests underlying pathology, malnutrition, or chronic illness. It does not indicate improvement and instead necessitates further medical investigation to rule out complications.
Choice C rationale
Transitioning to independent walking with a cane shows progress in gait stability and weight bearing tolerance on the prosthetic joint. This movement away from more restrictive assistive devices like walkers is a positive indicator of recovery.
Choice D rationale
Significant bruising and discoloration are concerning signs, potentially indicating a bleeding disorder or complications from ongoing anticoagulation therapy. This finding represents a setback or a new problem rather than a sign of successful clinical improvement.
Choice E rationale
Increased pain with movement in the surgical area suggests potential complications such as infection, prosthesis loosening, or hip dislocation. Expected progress involves a steady decrease in pain levels as the surgical site heals over the weeks.
Choice F rationale
The absence of shortness of breath and chest pain indicates that the pulmonary embolism has resolved and gas exchange is stable. This respiratory comfort suggests that pulmonary perfusion has been restored and the lungs are healing.
Choice G rationale
An oxygen saturation of 95 is within the normal range of 95 to 100 percent. This indicates adequate arterial oxygenation and demonstrates that the client no longer requires supplemental oxygen to maintain systemic tissue perfusion after recovery.
Choice H rationale
A visible hairline scar without redness, swelling, or drainage confirms successful primary intention healing of the surgical incision. This indicates that the skin integrity is restored and the risk of localized or systemic infection is decreasing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Managing disseminated intravascular coagulation involves identifying secondary complications of microvascular thrombosis and hemorrhage. Knowledge of coagulation pathways and end-organ perfusion assessment is required to differentiate between laboratory markers of the disease process and clinical indicators of worsening organ failure.
Choice A rationale
A prolonged prothrombin time, where the normal range is 11 to 13.5 seconds, is a diagnostic laboratory finding for this condition. However, it represents a hematological marker of the clotting cascade exhaustion rather than organ dysfunction.
Choice B rationale
Elevated D-dimer, with a normal range usually less than 500 ng/mL, indicates active fibrinolysis. While it confirms the presence of the disorder and ongoing clot breakdown, it is a laboratory value, not a clinical cue.
Choice C rationale
Capillary refill greater than 3 seconds indicates poor peripheral tissue perfusion. In this condition, microthrombi obstruct small vessels, leading to ischemia. A refill of 5 seconds signals significant circulatory compromise and potential progression toward multi-organ failure.
Choice D rationale
Petechiae and purpura are classic integumentary signs of bleeding due to thrombocytopenia and clotting factor depletion. While they signify active bleeding, they are considered standard symptoms of the disease rather than specific markers of organ dysfunction.
Choice E rationale
Decreased urine output, typically defined as less than 30 mL per hour, indicates impaired renal perfusion or acute kidney injury. This occurs due to microvascular thrombi in the renal capillaries, signaling significant organ dysfunction.
Choice F rationale
A normal platelet count, ranging from 150,000 to 450,000 cells/mm, would indicate improvement rather than worsening. In active cases, platelets are rapidly consumed, leading to severe thrombocytopenia as the body attempts to form micro-clots throughout the vasculature.
Correct Answer is C
Explanation
Postoperative care for intermaxillary fixation involves prioritizing the airway due to mechanical obstruction. Knowledge of airway management and emergency procedures is necessary to prevent life threatening complications associated with vomiting or secretions when the jaws are wired shut.
Choice A rationale
Pain management is important for postoperative recovery and client comfort. However, it is not the highest priority when compared to the immediate life threatening risk of an obstructed airway, which is common in clients with wired jaws.
Choice B rationale
Oral hygiene is necessary to prevent infection and maintain tissue integrity after mandibular surgery. While important for long term healing, it is a secondary concern that follows the immediate stabilization of respiratory function and airway clearance.
Choice C rationale
Intermaxillary fixation involves wiring the jaws together, making it impossible for the client to clear their airway if they vomit. Preventing aspiration is the priority because it can lead to immediate respiratory distress, pneumonia, or death.
Choice D rationale
Adequate nutrition is vital for bone healing and recovery after a fracture. However, nutritional needs are addressed once the client is stable and the airway is secured. Airway patency always takes precedence over metabolic or nutritional support.
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