Which of the following actions should the nurse take immediately to prevent complications?

Encourage the patient to cross their legs while dressing to reduce strain on the hip joint.

Allow the patient to continue dressing independently to promote mobility.

Stop the patient immediately and reinforce hip precautions, advising against hip flexion greater than 90 degrees.

Instruct the patient to bend forward slowly and use both hands to pull up the socks.

Answer and Explanation

The Correct Answer is C

A. Encourage the patient to cross their legs while dressing to reduce strain on the hip joint: Crossing the legs after hip surgery increases the risk of hip dislocation by placing excessive stress on the hip joint. This is incorrect and unsafe.

B. Allow the patient to continue dressing independently to promote mobility: While encouraging independence is important, allowing the patient to continue this action violates hip precautions (no bending past 90°). The patient must be stopped to prevent complications.

C. Stop the patient immediately and reinforce hip precautions, advising against hip flexion greater than 90 degrees. After THA, the hip should not be flexed more than 90° as this can cause hip dislocation. The nurse should stop the patient immediately and educate them on proper dressing techniques.

D. Instruct the patient to bend forward slowly and use both hands to pull up the socks. Bending forward, even slowly, violates hip precautions and increases the risk of dislocation. The patient should use adaptive devices, such as a sock aid, instead.

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Correct Answer is C

Explanation

A. Infection. Infection is a major concern in burn patients due to loss of skin integrity, but airway compromise is the most immediate life-threatening risk.

B. Paralytic ileus. Burn patients may develop paralytic ileus due to stress response and fluid shifts, but this is not the highest priority compared to airway obstruction.

C. Airway obstruction. Burns involving the face, neck, and chest increase the risk of airway swelling and obstruction. The nurse should assess for signs of respiratory distress, stridor, or hoarseness and be prepared for early intubation if needed.

D. Fluid imbalance. Fluid shifts can cause hypovolemia and shock, making fluid resuscitation critical. However, airway management remains the highest priority, especially in burns affecting the upper airway.

A. "Handwashing is not necessary since impetigo is not contagious." B. “I should apply Mupirocin (Bactroban) to the affected areas as prescribed." C. “I don't need to cover the lesions; they should be left open to the air." D. “I will let my child scratch the lesions to help them dry out faster."

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.

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Which of the following actions should the nurse take immediately to prevent complications?

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is C

Explanation

A nurse is providing discharge instructions to the parent of a child diagnosed with impetigo. Which of the following statements by the parent indicates a correct understanding of the treatment plan?

Correct Answer is B

Explanation

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

A nurse is caring for a patient post-total hip arthroplasty. Which of the following findings requires immediate intervention?

A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure?

A nurse is assessing a patient who sustained partial-thickness burns to the anterior chest and anterior left arm. Using the Rule of Nines, what percentage of total body surface area (TBSA) is affected?

A nurse is assessing a patient who has sustained a burn injury. The affected area is dry, white, and charred, with no pain present. Based on the classification of burns, the nurse understands this burn is:

A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider?

Which of the following statements by the patient indicates correct understanding of postoperative hip precautions?