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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Free Nursing Study Resources

Correct Answer is ["A","B","C"]

Explanation

These statements reflect the appropriate knowledge related to iron deficiency anemia. Iron-rich foods such as meat and beans can help increase iron levels in the body. Vitamin C aids in the absorption of iron, so taking a Vitamin C supplement can enhance iron absorption. Iron deficiency anemia is more common during pregnancy or menstruation due to increased iron demands.

However, increasing intake of dairy products alone does not address the iron deficiency. The statement about oral supplements not being as effective as monthly subcutaneous injections is incorrect, as oral iron supplements are commonly used to treat iron deficiency anemia and are effective in most cases.

A. Asking for nausea B. Evaluating for sacral redness C. Checking the respiratory rate D. Auscultating bowel sounds

Correct Answer is C

Explanation

Morphine is a potent opioid analgesic that can depress the respiratory system. Respiratory depression is a potential adverse effect of morphine, and it is essential for the nurse to monitor the patient's respiratory rate regularly to ensure adequate oxygenation and prevent respiratory complications.

By checking the respiratory rate, the nurse can assess if the patient is breathing adequately and detect any signs of respiratory depression. If the respiratory rate is significantly decreased or the patient shows signs of respiratory distress (e.g., shallow or irregular breathing), immediate intervention is necessary to address the situation promptly.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides education to a female patient diagnosed with iron deficiency anemia. Which patient statements indicate a correct understanding of iron deficiency? SELECT ALL THAT APPLY

Correct Answer is ["A","B","C"]

Explanation

The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient controlled analgesia (PCA). What action by the nurse is a priority?

Correct Answer is C

Explanation

The client is to receive an antibiotic 1 gram in 500 ml of fluid intravenously over 2 hours. At what rate will the nurse set the IV pump in mL/hr.? (Answer as whole number)

Therapeutic management for an adolescent with Crohn's Disease includes which treatment?

What is one airway complication that can occur during surgery when the patient is receiving general anesthesia care?

During the first few days after surgery for cleft lip, which intervention should the nurse implement?

A client had surgery yesterday and is reporting abdominal discomfort and lack of appetite. The nurse auscultates the abdomen and does not detect bowel sounds. The nurse suspected which type of bowel obstruction?

A student nurse correctly explains the pathophysiology of celiac when it is stated that patients who have celiac disease:

As a nurse caring for a school-age child, the nurse may anticipate which primary stressor/fear?