The medical-surgical nurse is caring for a client postoperatively after a total hip arthroplasty. The nurse is calculating the client's intake and output and notes a total of 100 mL of sanguineous drainage out of the hip drain in the 24 hours since surgery. What is the most appropriate action for the nurse to take?
Remove the drain
Continue to assess and monitor intake and output every shift
Elevate affected leg and place client in Trendelenburg position
Notify the surgeon and make aware of this finding
None of the above
The Correct Answer is B
Choice A reason: Removing the drain is not an appropriate action for the nurse to take, as it may cause bleeding, infection, or hematoma at the surgical site. The drain is placed to prevent the accumulation of fluid and blood in the hip joint, and it should be removed only by the surgeon when the drainage is minimal and the wound is healing.
Choice B reason: Continuing to assess and monitor intake and output every shift is an appropriate action for the nurse to take, as it helps to evaluate the fluid balance and the renal function of the client. The nurse should record the amount, color, and consistency of the drainage, and compare it with the previous measurements. The nurse should also monitor the vital signs, the hemoglobin and hematocrit levels, and the signs of dehydration or fluid overload.
Choice C reason: Elevating the affected leg and placing the client in Trendelenburg position is not an appropriate action for the nurse to take, as it may cause hip dislocation, hypotension, or respiratory distress. The nurse should keep the affected leg slightly abducted and aligned with the body, and avoid flexing the hip more than 90 degrees. The nurse should also maintain the client in a semi-Fowler's or supine position, and avoid turning the client to the affected side.
Choice D reason: Notifying the surgeon and making aware of this finding is not an appropriate action for the nurse to take, as it is not an urgent or abnormal situation. The nurse should report the drainage to the surgeon only if it exceeds the expected amount, which is usually less than 200 mL in the first 24 hours after surgery, or if it changes in color, consistency, or odor.
Choice E reason: None of the above is not a correct choice, as there is one option that matches the most appropriate action for the nurse to take.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Excess growth of bone formation does not cause the bones to weaken, but rather the opposite. Osteoporosis is a condition that causes the bones to lose density and become brittle due to the imbalance between bone resorption and formation. The bone resorption exceeds the bone formation, leading to low bone mass and increased fracture risk.
Choice B reason: Men are not less likely than women to have secondary causes of osteoporosis, but rather more likely. Secondary osteoporosis is a type of osteoporosis that is caused by other diseases or medications that affect the bone metabolism. Men are more likely to have secondary osteoporosis due to conditions such as hypogonadism, hyperparathyroidism, hyperthyroidism, or chronic kidney disease, or medications such as glucocorticoids, anticonvulsants, or anticoagulants.
Choice C reason: A modifiable risk factor for osteoporosis is a person's level of activity, as it affects the bone health and strength. Physical activity, especially weight-bearing and resistance exercises, can stimulate the bone formation and prevent the bone loss. It can also improve the muscle strength, balance, and coordination, which can reduce the risk of falls and fractures.
Choice D reason: Osteoporosis is not categorized as a disease for the elderly, but rather a disease that can affect people of any age. Osteoporosis is more common in older adults, especially postmenopausal women, due to the hormonal changes and the natural decline of bone mass with aging. However, osteoporosis can also occur in younger people due to genetic factors, lifestyle factors, or secondary causes.
Choice E reason: None of the above is not a correct choice, as there is one option that matches the most accurate statement related to osteoporosis.
Correct Answer is A
Explanation
Choice A reason: This statement indicates the need for further teaching, as it shows that the client does not understand the possible complication of postherpetic neuralgia, which is a chronic pain condition that can persist for months or years after the rash heals. The nurse should explain to the client that some people may experience this condition and that there are treatments available to manage the pain.
Choice B reason: This statement does not indicate the need for further teaching, as it shows that the client understands the importance of preventing the transmission of the virus to others, especially those who have not had chicken pox or the vaccine. The nurse should reinforce this behavior and remind the client to cover the rash with a dressing and avoid contact with pregnant women, newborns, and immunocompromised people.
Choice C reason: This statement does not indicate the need for further teaching, as it shows that the client knows the etiology of the infection. The nurse should confirm that the client is correct and explain that the virus remains dormant in the nerve cells after the initial infection and can reactivate later in life due to stress, aging, or other factors.
Choice D reason: This statement does not indicate the need for further teaching, as it shows that the client recognizes the prodromal symptom of the infection. The nurse should acknowledge that the client is correct and explain that the pain is caused by the inflammation of the nerve fibers where the virus resides. The nurse should also ask the client about the severity and frequency of the pain and provide appropriate interventions.
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