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 ["1.4"]
Explanation
We know that 7,000 units is equivalent to 5,000 units per ml. So, we can set up the proportion:
7,000 units / 5,000 units per ml = x ml / 1 ml x = 7,000 / 5,000
x = 1.4
Therefore, the nurse should administer 1.4 milliliters (ml) of heparin.
Correct Answer is C
Explanation
The patient bending over the sink while brushing teeth requires intervention by the nurse. After hip arthroplasty using the posterior approach, the patient should avoid bending at the hip greater than 90 degrees to prevent dislocation of the prosthesis. The nurse should instruct the patient to bend at the knees instead of the hips while brushing teeth or doing any other activity that requires bending. The other actions mentioned in the options are appropriate for a patient after hip arthroplasty.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today