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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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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.

A. Fever, tachypnea, and tachycardia B. Frequent stools, weight loss, and hyperactive bowels C. Frequent stools, fever, and tachycardia D. Constipation, fever, and weight loss

Correct Answer is B

Explanation

IBD, which includes conditions such as Crohn's disease and ulcerative colitis, is characterized by chronic inflammation of the gastrointestinal tract. The symptoms can vary depending on the type and severity of the disease, but common symptoms in children with IBD include:

Children with IBD often experience increased frequency of bowel movements, which may be loose or watery. This is often accompanied by urgency and a sense of incomplete evacuation.
Chronic inflammation in the gastrointestinal tract can interfere with nutrient absorption, leading to poor appetite, decreased intake, and subsequent weight loss. In severe cases, malnutrition may occur.
Inflammatory processes in the intestines can lead to increased motility and peristalsis, resulting in hyperactive bowel sounds.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is receiving Gabapentin (Neurontin), an anticonvulsant, but has no history of seizures. The nurse expects that the patient is receiving this drug for which condition?

Correct Answer is D

Explanation

A child is admitted to the hospital and diagnosed with inflammatory bowel disease. The nurse should evaluate the patient for which most likely associated symptoms?

Correct Answer is B

Explanation

The nurse is caring for an infant with a hip spica cast who has just returned from surgery. Which nursing action will be priority for this patient?

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

An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to:

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What are the most important nursing interventions for clients with possible renal calculi? List two.

The nurse is caring for an adolescent diagnosed with scoliosis who just arrived to the floor from the recovery room after a Spinal fusion surgery. The nurse should question which physician order?

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?

What is the priority action the nurse will take for a 4-year old client admitted with minimal change nephrotic syndrome (MCNS) who has hypertension and facial edema?