A nurse is caring for an older adult client who has had a total hip arthroplasty.
For each potential precaution, click to specify if the precaution is indicated or contraindicated for a client who has had a total hip arthroplasty.
Request an antiemetic medication.
Encourage the client to cough and deep breathe every 2 hr.
Ensure an abductor pillow is in place while the client is in bed.
Anticipate the administration of antibiotics.
Obtain a culture of the drainage from the surgical site.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
- Request an antiemetic medication: Contraindicated
- Rationale: Antiemetic medications are not typically required unless the client is experiencing nausea or vomiting, which is not indicated in this scenario.
- Encourage the client to cough and deep breathe every 2 hr: Indicated
- Rationale: Encouraging coughing and deep breathing helps prevent respiratory complications such as pneumonia, which is important postoperatively.
- Ensure an abductor pillow is in place while the client is in bed: Indicated
- Rationale: An abductor pillow helps maintain proper hip alignment and prevents dislocation of the hip joint after surgery.
- Anticipate the administration of antibiotics: Indicated
- Rationale: Administering antibiotics helps prevent infection, which is a common concern after surgical procedures.
- Obtain a culture of the drainage from the surgical site: Indicated
- Rationale: Obtaining a culture of the drainage can help identify any potential infections and guide appropriate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The P wave represents atrial depolarization. It is the electrical impulse that triggers the contraction of the atria. The P wave is the first wave in the ECG cycle and indicates the initiation of the heart's electrical activity from the sinoatrial (SA) node.
B. Ventricular depolarization is represented by the QRS complex, not the P wave. The QRS complex indicates the electrical activity that leads to the contraction of the ventricles.
C. Early ventricular repolarization is represented by the T wave, not the P wave. The T wave reflects the process of the ventricles returning to their resting state after contraction.
D. Slow repolarization of ventricular Purkinje fibers is not represented by the P wave. This process occurs during the T wave, which reflects the repolarization of the ventricles.
Correct Answer is D
Explanation
A. Offering reassurance is important for addressing anxiety, but it is not the immediate priority in this situation. The patient's difficulty in clearing thick respiratory secretions should be addressed first to prevent further complications.
B. Applying humidification to the oxygen may help loosen secretions over time, but it does not provide immediate relief. The priority is to clear the airway to ensure adequate oxygenation and prevent aspiration.
C. Encouraging the patient to increase oral fluid intake is helpful in the long term for thinning secretions, but it does not address the immediate problem of difficulty in coughing up thick secretions.
D. Suctioning the tracheostomy is the priority action. The patient is unable to clear thick secretions, and suctioning is necessary to remove the obstruction and improve airway patency, which will also alleviate anxiety and improve oxygenation.
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