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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Gabapentin (Neurontin) is often used to treat neuropathic pain, including pain associated with peripheral neuropathy. It may also be used to manage other types of chronic pain, such as pain associated with fibromyalgia. While gabapentin is primarily an anticonvulsant medication, it is also used off-label for various other conditions, such as mood disorders and anxiety.
Correct Answer is C
Explanation
Hemoglobin A1C is a blood test that provides an average blood glucose level over the past 2-3 months. Regular monitoring of A1C levels helps to assess the effectiveness of lifestyle modifications and treatment plans and guides adjustments in management if necessary.
Daily exercise is another essential aspect of managing pre-diabetes. Regular physical activity helps improve insulin sensitivity, promotes weight management, and reduces the risk of developing type 2 diabetes. The nurse should educate patients on the importance of incorporating physical activity into their daily routine and provide recommendations on suitable exercise types and durations.
While other options may be relevant for patients with diabetes, they are not specifically tailored to pre-diabetes, which is a condition where blood glucose levels are higher than normal but not yet meeting the criteria for diabetes.
Hypoglycemia and injection site infection are more relevant concerns for individuals with diabetes who require insulin or other medications to manage their blood sugar levels. Increasing carbohydrate intake and administering insulin are not appropriate recommendations for pre-diabetes management, as they can contribute to elevated blood glucose levels.
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