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 C

Explanation

Taking an extra dose of Aspirin prior to surgery can significantly increase the risk of bleeding during and after the surgical procedure. Aspirin is a non-steroidal anti-inflammatory drug (NSAID) that can interfere with the normal blood clotting process. Surgical procedures often require meticulous control of bleeding, and the presence of Aspirin in the patient's system can pose a significant risk.

It is essential for patients to follow preoperative instructions provided by the healthcare team, including avoiding certain medications or substances that can increase the risk of complications during surgery. Taking an extra dose of Aspirin, especially without consulting the healthcare provider, can jeopardize the safety of the surgical procedure and may require rescheduling to ensure the patient's well-being.

A. Urine output and electrolyte levels. B. Understanding of how to prevent falls. C. Peripheral vascular perfusion and pain. D. Risk for bleeding and white blood cell count (WBC)

Correct Answer is A

Explanation

Acute renal failure is characterized by a sudden decline in kidney function, resulting in the inability of the kidneys to adequately filter waste products and maintain fluid and electrolyte balance. Monitoring urine output is essential in assessing kidney function and determining the severity of renal failure. A decrease in urine output or anuria may indicate worsening renal function and the need for immediate interventions.

Assessing electrolyte levels, such as sodium, potassium, calcium, and phosphorus, is crucial because renal failure can disrupt the balance of these electrolytes in the body. Imbalances can lead to complications such as electrolyte abnormalities, cardiac dysrhythmias, and neuromuscular disturbances. Prompt identification and management of electrolyte imbalances are essential in preventing further complications and supporting optimal patient outcomes.

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