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A nurse is providing discharge instructions to a client who is postoperative following a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I will use a raised toilet seat.
- C. I will sleep on my affected side.
- D. I will perform leg exercises every hour while awake.
Correct Answer: C
Rationale: The correct answer is C. Sleeping on the affected side could increase the risk of dislocation following a hip arthroplasty. It is essential for the client to avoid sleeping on the surgical side to prevent complications. Choices A, B, and D are correct statements that promote proper postoperative care and reduce the risk of complications. Avoiding crossing legs when sitting, using a raised toilet seat for proper positioning, and performing leg exercises regularly help in the recovery process and prevent complications.
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How should a healthcare professional manage a patient with non-compliance to hypertension medication?
- A. Provide education on medication
- B. Refer the patient to a specialist
- C. Discontinue the medication
- D. Reassess the patient in 6 months
Correct Answer: A
Rationale: Providing education on medication is crucial when managing a patient with non-compliance to hypertension medication. By educating the patient on the importance of adherence, potential side effects, and the impact of uncontrolled hypertension, healthcare professionals can help improve the patient's understanding and compliance. Referring the patient to a specialist (Choice B) may be necessary in some cases but should not be the first step. Discontinuing the medication (Choice C) without exploring reasons for non-compliance and providing education can worsen the patient's condition. Reassessing the patient in 6 months (Choice D) is important but should be accompanied by interventions to address non-compliance in the interim.
A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings is the priority for the nurse to report?
- A. Heart rate of 90/min
- B. Blood pressure of 118/76 mm Hg
- C. Warmth and redness in the calf
- D. Pink-tinged urine
Correct Answer: C
Rationale: The correct answer is C, warmth and redness in the calf. These symptoms may indicate a deep vein thrombosis (DVT), a serious complication following hip arthroplasty that requires immediate attention. A heart rate of 90/min and blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client and do not indicate an urgent issue. Pink-tinged urine may suggest blood in the urine, which should be monitored but is not as critical as the potential DVT.
What is the best way to manage a patient's pain postoperatively?
- A. Administer analgesics regularly
- B. Administer pain medication PRN
- C. Encourage deep breathing exercises
- D. Provide distraction techniques
Correct Answer: A
Rationale: The correct answer is A: Administer analgesics regularly. Postoperative pain management often requires a scheduled, around-the-clock administration of analgesics to maintain a consistent level of pain relief and minimize the risk of breakthrough pain. Choice B, administering pain medication PRN (as needed), may lead to inadequate pain control as the medication is not given preemptively. Choice C, encouraging deep breathing exercises, can be beneficial for pain management but should be used as an adjunct to analgesic therapy. Choice D, providing distraction techniques, may help some patients cope with pain but should not be the primary method of pain management postoperatively.
A nurse is assessing a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?
- A. Lipsmacking
- B. Agranulocytosis
- C. Clang association
- D. Alopecia
Correct Answer: A
Rationale: Lipsmacking is a common sign of tardive dyskinesia, a long-term side effect of haloperidol. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements such as lipsmacking, tongue protrusion, and facial grimacing. Agranulocytosis (choice B) is a potential side effect of antipsychotic medications but is not specifically associated with haloperidol. Clang association (choice C) is a form of disorganized speech seen in conditions like schizophrenia but is not a side effect of haloperidol. Alopecia (choice D) refers to hair loss and is not a common long-term side effect of haloperidol.
A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?
- A. Fetal hypoxia
- B. Abruptio placentae
- C. Post maturity
- D. Head compression
Correct Answer: D
Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.