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 B
Explanation
Excess body weight, particularly in the abdominal area, can increase intra-abdominal pressure and lead to the weakening of the lower esophageal sphincter (LES). The LES is responsible for preventing stomach acid from flowing back into the esophagus. When it becomes weakened, it can contribute to the development of GERD. Other risk factors for GERD include certain dietary choices, such as consuming fatty and spicy foods, smoking, pregnancy, and alcohol consumption.
Correct Answer is C
Explanation
Crohn's Disease is an inflammatory bowel disease that can affect any part of the digestive tract. The goal of treatment is to control inflammation, relieve symptoms, and prevent complications. To achieve this, the healthcare provider may prescribe medication such as anti-inflammatory drugs, immunosuppressants, or biologic therapies that target specific inflammatory pathways.
These medications can help reduce inflammation and improve symptoms.
In addition to medication, nutritional therapy may also be recommended to help manage Crohn's Disease. However, dietary restrictions to reduce calorie and fat intake to lose weight or restrict foods containing gluten to control symptoms are not specific treatments for Crohn's Disease.
Keeping the child in isolation to prevent the spread of the infection is not relevant to Crohn's Disease, as it is not contagious.
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