Nokea
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Maintain abduction of the affected extremity.
- B. Position the client in high Fowlers position.
- C. Encourage the client to cross their legs at the ankles.
- D. Have the client bend forward at the waist while sitting.
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. This is crucial post total hip arthroplasty to prevent dislocation. Abduction helps keep the hip joint stable and reduces the risk of the prosthesis slipping out of place. Choices B, C, and D are incorrect. High Fowler's position (B) is not necessary for this specific postoperative care. Crossing legs at the ankles (C) can lead to hip dislocation. Having the client bend forward at the waist (D) can also increase the risk of dislocation.
You may also like to solve these questions
A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy?
- A. BUN 24 mg/dL
- B. Blood glucose 95 mg/dL
- C. Platelets 250
- D. 000/mm³
- E. Hemoglobin 14 g/Dl
Correct Answer: A
Rationale: The correct answer is A: BUN 24 mg/dL. Cyclosporine, an immunosuppressant medication, can cause nephrotoxicity as an adverse effect. An elevated BUN level indicates impaired kidney function, which can be a consequence of cyclosporine therapy. Blood glucose level (choice B) and platelet count (choice C) are not typically affected by cyclosporine. Hemoglobin level (choice E) is not directly related to cyclosporine therapy. Therefore, the nurse should be vigilant for signs of nephrotoxicity by monitoring the client's BUN level.
A nurse is providing preoperative teaching to a client who is scheduled for a radical prostatectomy. Which of the following information should the nurse include in the teaching?
- A. You will have a urinary catheter for several days.
- B. A PCA pump will be used for postoperative pain control.
- C. You will be discharged the same day as surgery.
- D. You should avoid all fluid intake after surgery.
Correct Answer: B
Rationale: The correct answer is B: A PCA pump will be used for postoperative pain control. This is crucial information for the client undergoing a radical prostatectomy as it ensures effective pain management post-surgery. The use of a PCA pump allows the client to self-administer pain medication within safe limits, promoting better pain control and comfort during the recovery period. It also empowers the client to actively participate in their pain management.
Choice A is incorrect because while the client may have a urinary catheter after surgery, it is not the most crucial information to include in preoperative teaching.
Choice C is incorrect as radical prostatectomy typically requires a hospital stay, not same-day discharge.
Choice D is incorrect as avoiding all fluid intake after surgery is not recommended; adequate hydration is important for recovery.
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the clients risk for ventilator-associated pneumonia (VAP)? (Select all that apply.)
- A. Wear a protective gown when suctioning the clients airway.
- B. Monitor for oral secretions every 2 hr.
- C. Provide oral care every 2 hr.
- D. Maintain the client in a supine position.
- E. Assess the client daily for readiness of extubation.
Correct Answer: B, C, E
Rationale: Correct Answer: B, C, E
Rationale:
- Monitoring for oral secretions every 2 hr helps prevent aspiration of secretions, reducing the risk of VAP.
- Providing oral care every 2 hr reduces the bacterial load in the mouth, decreasing the risk of VAP.
- Assessing the client daily for readiness of extubation allows for timely removal of the ventilator, reducing the duration of ventilation and lowering the risk of VAP.
Incorrect Choices:
- Wearing a protective gown when suctioning the client's airway does not directly decrease the risk of VAP.
- Maintaining the client in a supine position may increase the risk of aspiration and VAP.
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
- A. Red-tinged drainage on the dressing
- B. Cloudy urine in the catheter
- C. Clear drainage on the dressings
- D. Mild back pain at the surgical site
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice D) is common after this surgery and does not necessarily indicate a complication.
A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will eat a high-protein diet before exercise.
- B. I will check my blood sugar level before exercising.
- C. I will avoid all forms of sugar.
- D. I will only take my insulin when I feel symptoms of high blood sugar.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Checking blood sugar before exercise is crucial for individuals with type 1 diabetes to prevent hypoglycemia.
2. It allows the client to adjust their insulin dosage or carbohydrate intake based on their blood sugar level.
3. Monitoring blood sugar helps maintain safe levels during physical activity.
4. Other choices are incorrect as high-protein diet may not be necessary, avoiding all sugar is extreme, and insulin should be taken as prescribed, not based on symptoms.