A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take?

Teach the client which positions to avoid during PT.

Identify the client's pain level and medicate if needed.

Perform the client's morning care.

Encourage the client to use full weight bearing.

Answer and Explanation

The Correct Answer is B

B. Assessing the client's pain level is crucial, especially before physical therapy, as pain can affect participation and compliance with therapy. If the client is experiencing pain, appropriate pain management measures should be implemented before PT to optimize participation and comfort.

A. The nurse should educate the client on proper body mechanics and positions to avoid during physical therapy to promote safe movement and prevent complications. However, this is not a priority.

C. While morning care is important for maintaining hygiene and comfort, it may not be the priority at this specific time, especially if the client is scheduled for physical therapy soon.

D. Encouraging full weight bearing immediately postoperative may not be appropriate, as the surgical site needs time to heal and regain strength.

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Correct Answer is ["A","D"]

Explanation

A. The heart rate has increased from 92/min on Day 1 to 108/min on Day 2. This significant increase warrants immediate follow-up as it may indicate pain, anxiety, or an underlying physiological issue such as hemorrhage, infection, or cardiac complications.

D. The temperature has increased from 36.4°C (97.5°F) on Day 1 to 37.2°C (98.9°F) on Day 2. While this increase is within a relatively normal range, it is approaching a fever range (> 38°C or 100.4°F) and warrants further evaluation to determine if there is an underlying infection or inflammation.

B. The oxygen saturation remains relatively stable, from 95% on Day 1 to 96% on Day 2. While it is important to monitor oxygen saturation, the minimal change does not indicate an immediate concern. However, it should still be monitored closely for any further decrease.

C. Edema is not directly mentioned in the provided data. While edema can be indicative of various health issues, there is no evidence in the given information to suggest its presence or severity as a concern requiring immediate follow-up.

E. Urine color is not provided in the given data. While changes in urine color can indicate dehydration or other health issues, it is not mentioned in the assessment findings and therefore not a factor for immediate follow-up based on the information provided.

F Pedal pulses were noted as +2 on Day 1, indicating that they were present and normal. Unless there is a significant change in pedal pulses or signs of vascular compromise, such as decreased or absent pulses, there is no immediate need for follow-up based on the given information.

A. The right time B. The right medication C. The right dose D. The right color E. The right patient F. The right taste

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

Explanation

A. Administering medication at the right time helps maintain therapeutic drug levels in the patient's system and ensures optimal treatment outcomes.

B. This means administering the correct medication to the patient as prescribed by the healthcare provider. It's crucial to verify the medication name, strength, and dosage form to prevent medication errors and adverse drug reactions.

C. It's essential to double-check the dose calculation and verify it against the prescription to prevent medication errors, especially with high-risk medications.

E. This means administering the medication to the correct patient. It's essential to verify the patient's identity using at least two patient identifiers (such as name and date of birth) before administering any medication to ensure it is being given to the intended recipient.

D. The color of medication is not typically considered one of the medication rights. While certain medications may have specific color coding for identification purposes, relying solely on color to identify a medication can be misleading and increase the risk of errors.

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A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department (ED). Exhibits Select the 4 assessment findings on day 2 that require immediate follow-up.

Correct Answer is ["A","D"]

Explanation

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

Explanation

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