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 A

Explanation

After spinal fusion surgery, it is important to limit the patient's activity and movement to allow for proper healing and to prevent complications. The order to have the patient out of bed three times daily and ad lib (as desired) is not appropriate immediately after surgery.

The other orders listed are appropriate for the postoperative care of a patient who has undergone spinal fusion surgery:

Assess neurological status every 4 hours: This is important to monitor for any changes in neurological function, which could indicate complications such as nerve damage or spinal cord compression.
Logroll only to change position: Logrolling is a technique used to move patients with spinal fusion surgery while keeping their spine aligned and minimizing stress on the surgical site. This order is appropriate to ensure proper positioning and prevent injury to the surgical area.
Monitor vital signs every 4 hours: Monitoring vital signs helps to assess the patient's overall condition and detect any signs of complications such as bleeding or infection.

A. Prevent blood clots B. Prevent malignant hyperthermia. C. Promote fracture healing. D. Reduce pain E. Prevent fat embolism

Correct Answer is ["C","D","E"]

Explanation

The nurse explains that immobilizing a fracture will:

Help align the bone fragments and reduce movement, which is crucial for proper healing. Immobilization can help maintain the stability of the fracture site, allowing the bones to knit together and heal.
Help to minimize movement and subsequent pain. It provides support and reduces stress on the injured area, which can help alleviate discomfort and promote a more comfortable healing process.
Help to minimize movement and reduce the risk of fat globules from bone marrow entering the bloodstream and causing a fat embolism, a potentially serious complication.

Preventing blood clots, preventing malignant hyperthermia, and immobilizing a fracture are not directly related. Preventing blood clots typically involves other measures such as early mobilization, elevation, and medication to prevent deep vein thrombosis. Malignant hyperthermia is a rare, potentially life-threatening reaction to certain medications used during anesthesia, and immobilization does not directly prevent it.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

Why it is important to immobilize a suspected fracture. The nurse explains that immobilizing a fracture will... (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

After a change-of-shift report, which client should the nurse assess first?

A client's Sodium level is 128 meq/L. The nurse knows that a likely cause of this lab finding is:

Heparin 7,000 units is ordered. Heparin 5,000 units per ml is available. How many milliliters (ml) should the nurse administer? (Do not round)

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In replying to a client's questions about the seriousness of the chronic kidney disease (CKD), the nurse knows that the stage of CKD is based on what?

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