A nurse is caring for a patient post-total hip arthroplasty. Which of the following findings requires immediate intervention?
The surgical dressing has a small amount of serosanguinous drainage.
The patient's hemoglobin dropped from 12 g/dL to 10 g/dL within 24 hours postoperatively.
The patient reports mild discomfort at the surgical site and rates pain as 4/10 on a pain scale.
The surgical extremity is cool to touch, pale, with weak pedal pulses compared to the contralateral limb.
The Correct Answer is D
A. The surgical dressing has a small amount of serosanguinous drainage. Light serosanguinous drainage is expected postoperatively and does not require immediate intervention.
B. The patient’s hemoglobin dropped from 12 g/dL to 10 g/dL within 24 hours postoperatively. A mild drop in hemoglobin postoperatively is expected due to blood loss during surgery. This does not require immediate intervention.
C. The patient reports mild discomfort at the surgical site and rates pain as 4/10 on a pain scale. Mild discomfort is expected and can be managed with prescribed analgesics.
D. The surgical extremity is cool to touch, pale, with weak pedal pulses compared to the contralateral limb. These findings indicate impaired circulation or vascular compromise, which could suggest compartment syndrome or arterial occlusion. Immediate intervention is required to prevent limb ischemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Handwashing is not necessary since impetigo is not contagious." Impetigo is highly contagious, and proper hand hygiene is essential to prevent its spread to others.
B. “I should apply Mupirocin (Bactroban) to the affected areas as prescribed." Mupirocin (Bactroban) is the standard topical antibiotic treatment for impetigo and should be applied as prescribed to reduce bacterial colonization and promote healing.
C. “I don't need to cover the lesions; they should be left open to the air." Covering the lesions can help prevent the spread of infection by minimizing contact with contaminated surfaces.
D. “I will let my child scratch the lesions to help them dry out faster." Scratching can worsen the infection, spread bacteria to other parts of the body, and lead to secondary infections.
Correct Answer is D
Explanation
A. Hematocrit 40%: A hematocrit level of 40% is within the normal range for adult females (36%-48%) and does not require intervention.
B. Potassium 3.8 mEq/L: Normal potassium levels range from 3.5-5.0 mEq/L, so a value of 3.8 mEq/L is within normal limits and does not pose a risk for surgery.
C. Creatinine 0.9 mg/dL: Normal creatinine levels for adult females are 0.5-1.1 mg/dL. A level of 0.9 mg/dL indicates normal kidney function and does not require reporting.
D. WBC count 20,000/mm³: A WBC count of 20,000/mm³ is significantly elevated, indicating a possible infection or inflammatory response. This increases the risk of post-operative complications and should be reported to the surgeon immediately.
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