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 A
Explanation
Recombinant human erythropoietin is a medication commonly used in the treatment of anemia associated with chronic renal failure. It stimulates the production of red blood cells in the bone marrow, helping to improve anemia.
The other statements mentioned do not accurately reflect the expected outcomes or effects of recombinant human erythropoietin:
Chronic renal failure leads to impaired kidney function, and while recombinant human erythropoietin can help address anemia, it does not directly improve creatinine (Cr) and blood urea nitrogen (BUN) levels, which are markers of kidney function.
Furosemide is a diuretic commonly used in the management of fluid retention in renal failure. Recombinant human erythropoietin does not replace or eliminate the need for diuretic therapy.
Chronic renal failure typically involves decreased kidney function and impaired urine production. Recombinant human erythropoietin does not directly affect urine output.
Correct Answer is C
Explanation
Prednisone is a corticosteroid medication that can increase blood glucose levels by promoting gluconeogenesis (the production of glucose from non-carbohydrate sources) and reducing glucose utilization in the body. This can lead to elevated blood sugar levels, especially in individuals with diabetes. The client's history of urinary tract infection and the use of Prednisone suggest that the infection might have triggered the development of DKA.
It's important to note that DKA can occur even when a person is taking insulin as prescribed and following their diet carefully if other factors contribute to the development of DKA, such as an underlying infection or the use of certain medications like Prednisone. The nurse should further assess the client's condition and notify the healthcare provider to initiate appropriate management for DKA.
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