The nurse turns a 2-day postoperative patient with a right total hip replacement using pillows between the legs. The nurse later returns and finds the patient lying supine with legs crossed. Which of the following should the nurse immediately observe to determine whether a complication has developed?

The right leg for shortening

The left leg for internal rotation

The left leg for loss of function

The right knee for crepitation

Answer and Explanation

The Correct Answer is A

Correct answer: A
A. The right leg for shortening: This is the most critical observation because crossing the legs after a hip replacement can cause hip dislocation. A shortened leg can be a sign of dislocation, which is a serious complication that requires immediate attention.
B. The left leg for internal rotation: Internal rotation is more of a concern for the operated leg (the right leg), not the left leg, in this context.
C. The left leg for loss of function: This is less relevant unless there is concern about a complication in the left leg, which is not directly related to the issue of crossing legs post-surgery.
D. The right knee for crepitation: Crepitation refers to a crackling sound and is more associated with joint issues rather than an indicator of hip dislocation.

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Correct Answer is A

Explanation

Correct answer: A
A. Monitoring for infection: Infection is a significant risk with external fixation devices due to the presence of pins that penetrate the skin and soft tissues. Monitoring for signs of infection, such as redness, swelling, discharge, or increased pain, is crucial.
B. Monitoring circulatory status: While circulatory status is important, especially in cases of limb injury or immobilization, it is not the most immediate concern compared to the risk of infection from the external fixation device.
C. Validating proper mobility: Ensuring proper mobility is important, but it is secondary to the prevention and detection of infection. Mobility assessments can be done after confirming that there are no infections or complications.
D. Checking discomfort level: While assessing discomfort is important for pain management and comfort, it is not as critical as monitoring for infection, which can lead to severe complications if not addressed promptly.

A. “Take off work for the rest of the day to rest at home." B. "Return to work and have your blood pressure rechecked in 2 days." C. "Take two doses of blood pressure medication right now." D. "Sit quietly while we call 911 to request an ambulance."

Correct Answer is D

Explanation

A. “Take off work for the rest of the day to rest at home.": This advice is not adequate for such a high blood pressure reading, which indicates a hypertensive crisis that requires immediate medical intervention.
B. "Return to work and have your blood pressure rechecked in 2 days.": This is inappropriate as it delays necessary urgent medical evaluation and treatment.
C. "Take two doses of blood pressure medication right now.": Without medical supervision, this could be dangerous and is not appropriate in an emergency situation where the blood pressure is critically high.
D. "Sit quietly while we call 911 to request an ambulance.": A blood pressure of 220/120 mm Hg suggests a hypertensive emergency, which can lead to life-threatening complications like stroke or heart attack. The patient needs immediate medical attention, and calling 911 is the appropriate response.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing for a home visit to a patient with an external fixation device of the lower extremity. What priority care is anticipated?

Correct Answer is A

Explanation

During a health screening, a patient's blood pressure is confirmed by two clinic nurses to be 220/120 mm Hg. Which of the following actions should the nurse recommend to the patient?

Correct Answer is D

Explanation

When taking blood pressure medications, it is important to reinforce education with the patient on which topics? Select all that apply.

The nurse is providing teaching to a patient with Buerger disease. Which of the following statements by the patient would the nurse evaluate as indicating understanding about Buerger disease?

The nurse is contributing to the plan of care for a patient who has a traumatic finger amputation. What should the nurse consider?

The nurse is providing care for a patient with expressive aphasia. Which intervention does the nurse expect to find in the patient's plan of care? (Select all that apply.)

A patient with osteoarthritis who had a right total knee replacement tells the nurse that the other knee is becoming painful. Which of the following is the most appropriate instruction to help the patient preserve function of the left knee?

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