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
Unequal scapula and hip heights can be indicative of spinal curvature, a key characteristic of scoliosis. As the spine curves, it can cause the shoulders and hips to appear uneven when observed from behind. This asymmetry is an important visual clue that warrants further assessment and evaluation.
Equal rib prominence and tight-fitting clothes, equal waist and shoulder angles, and symmetric chest expansion with deep breaths are not specific signs of scoliosis. These signs may not be affected by spinal curvature and are not typically used in the screening process for scoliosis.
It's important to note that scoliosis screenings may involve more comprehensive assessments, including the use of scoliometers or other measuring tools to evaluate the degree of spinal curvature. Any concerns or suspicions of scoliosis should be reported to appropriate healthcare professionals for further evaluation and management.
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.
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