A nurse is caring for a client who is 1-day post-total hip replacement surgery. Assessment findings are as follows.

Assessment

Vital Signs BP 112/68 mmHg

Heart rate 75 beats/min. Respirations 18 breaths/min 02 saturation 90%, room air Surgical site clean, dry, intact

Lung sounds clear upper lobes, diminished lower lobes.

Pain 2/10

Which action by the nurse is most appropriate at this time?

Administer the antibiotic earlier than scheduled.

Administer pain medication.

Have the client use the incentive spirometer.

Change the dressing over the wound.

Answer and Explanation

The Correct Answer is C

The assessment findings indicate that the client has diminished lung sounds in the lower lobes, suggesting potential postoperative atelectasis or decreased air movement in the lungs. Using an incentive spirometer can help improve lung expansion and prevent respiratory complications such as pneumonia. It is important to address this issue promptly to prevent further deterioration of lung function.

Administering pain medication may be necessary depending on the client's level of pain, but addressing the respiratory issue takes priority in this situation.

Administering the antibiotic earlier than scheduled or changing the dressing over the wound may not be indicated based on the provided assessment findings.

Therefore, having the client use the incentive spirometer is the most appropriate action at this time to promote optimal lung function and prevent respiratory complications.

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Correct Answer is D

Explanation

Nausea and vomiting can lead to excessive loss of fluids and electrolytes, including potassium, from the body. Gastroenteritis is an inflammation of the gastrointestinal tract typically caused by viral or bacterial infections. It is commonly characterized by symptoms such as diarrhea, vomiting, abdominal pain, and fever. Antibiotics are not typically used to treat viral gastroenteritis and would not directly cause the electrolyte imbalance. Administration of IV Furosemide, a diuretic, would increase urine output but is not typically used to treat gastroenteritis. The fever itself may contribute to fluid loss but would not directly cause the electrolyte imbalance.

A. Explain procedures and routines. B. Provide for privacy. C. Encourage the parents to room in. D. Encourage contact with children the same age.

Correct Answer is C

Explanation

Toddlers often experience separation anxiety when separated from their primary caregivers. Having the parents stay with the child in the hospital, commonly known as rooming in, can provide a sense of security and familiarity, which helps alleviate separation anxiety. It allows the child to have a consistent presence and promotes a nurturing and comforting environment.

While explaining procedures and routines can be helpful, it may not fully address the underlying separation anxiety experienced by the toddler. Providing for privacy and encouraging contact with children the same age may not directly address the primary source of anxiety, which is being separated from the parents.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is C

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