A nurse is receiving a report on a client who has just returned from the operating room after undergoing a total hip arthroplasty.
Which of the following information should the nurse obtain from the report?
The type and size of the prosthesis used.
The amount and color of urine output during surgery.
The type and dose of anesthesia administered.
The presence and quality of pedal pulses on both legs.
The Correct Answer is D
The presence and quality of pedal pulses on both legs.
Rationale: The nurse should obtain information on the presence and quality of pedal pulses on both legs from the report, as this indicates the adequacy of blood circulation and perfusion to the lower extremities, which can be compromised by surgery, positioning, or complications such as thromboembolism or compartment syndrome.
Incorrect options:
A) The type and size of the prosthesis used may be important information for the surgical team and the client's medical record, but it is not immediately relevant to the immediate post-operative care provided by the nurse.
B) The amount and color of urine output during surgery is not directly related to the client's condition after a total hip arthroplasty and is not the primary focus of the nurse's assessment at this time.
C) The type and dose of anesthesia administered is important information for the client's medical record and may have implications for post-operative care, but it is not the most critical information for the nurse to obtain immediately upon receiving the report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client's blood pressure is 180/100 mm Hg and heart rate is 110 beats/min.
Rationale: The nurse should report the client's blood pressure and heart rate to the provider immediately, as these are signs of hypertensive crisis and tachycardia, which can indicate a serious cardiovascular complication, such as myocardial infarction, stroke, or heart failure.
Incorrect options:
A) The client has a history of hypertension and diabetes mellitus. - This is an important information to obtain from the client, as it indicates risk factors for cardiovascular disease. However, this is not an urgent finding that requires immediate reporting to the provider, as it does not reflect the client's current condition or acuity.
B) The client takes aspirin 81 mg daily and metformin 500 mg twice daily. - This is an important information to obtain from the client, as it indicates the medications that the client is taking for their chronic conditions. However, this is not an urgent finding that requires immediate reporting to the provider, as it does not reflect any adverse effects or interactions of these medications.
D) The client's chest pain radiates to the left arm and is relieved by nitroglycerin. - This is an important information to obtain from the client, as it indicates that the client has angina pectoris, which is chest pain caused by reduced blood flow to the heart muscle. However, this is not an urgent finding that requires immediate reporting to the provider, as it shows that the chest pain is stable and responsive to nitroglycerin.
Correct Answer is A
Explanation
"Wash your hands with warm water and soap before testing."
Rationale: The nurse should instruct the client to wash their hands with warm water and soap before testing, as this helps to prevent infection and remove any substances that may interfere with the accuracy of the test result.
Incorrect options:
B) "Use alcohol wipes to clean your finger before pricking it." - This is an incorrect instruction, as using alcohol wipes to clean the finger can dry out and irritate the skin, and may also affect the test result if the alcohol is not completely dry before pricking.
C) "Squeeze your finger firmly to obtain a drop of blood." - This is an incorrect instruction, as squeezing the finger firmly can cause hemolysis or dilution of the blood sample, leading to inaccurate readings. The client should apply gentle pressure to the finger after pricking it.
D) "Choose a different finger for each test throughout the day." - This is an incorrect instruction, as choosing a different finger for each test throughout the day can increase the risk of infection and pain. The client should rotate the testing sites within one finger or use alternate sites, such as the forearm or palm.
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