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A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include?
- A. Cross your legs when sitting to increase circulation.
- B. Bend at the waist when picking up objects.
- C. Avoid crossing your legs when sitting.
- D. Avoid using a raised toilet seat.
Correct Answer: C
Rationale: The correct answer is C: 'Avoid crossing your legs when sitting.' After a total hip arthroplasty, it is important for clients to avoid crossing their legs to prevent complications such as dislocation. Crossing the legs can put strain on the new hip joint, increasing the risk of dislocation. Choice A is incorrect as crossing legs can be harmful. Choice B is incorrect as bending at the waist can strain the hip joint, leading to complications. Choice D is incorrect as using a raised toilet seat is recommended after hip surgery to prevent excessive bending at the hip joint.
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How should signs of infection in a post-surgical patient be assessed?
- A. Check the surgical site
- B. Check the patient's vital signs
- C. Monitor for fever
- D. Check for abnormal breath sounds
Correct Answer: A
Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.
How should bleeding in a patient on warfarin be monitored?
- A. Monitor INR levels
- B. Monitor hemoglobin levels
- C. Monitor potassium levels
- D. Monitor platelet count
Correct Answer: A
Rationale: The correct answer is to monitor INR levels. INR levels are the most critical indicator for monitoring bleeding risk in patients on warfarin. INR stands for International Normalized Ratio and specifically measures the clotting tendency of the blood. Monitoring hemoglobin levels, potassium levels, or platelet count are not as directly relevant to assessing bleeding risk in patients on warfarin.
A nurse is reviewing the medical record of a client who is at 30 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 140/90 mm Hg
- B. 1+ pitting edema in the lower extremities
- C. Weight gain of 2.3 kg (5 lb) in 1 week
- D. Mild headache
Correct Answer: C
Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening preeclampsia due to fluid retention, which can lead to serious complications. This finding should be reported promptly to the provider for further assessment and intervention. Blood pressure of 140/90 mm Hg is high but may not be an immediate concern for a client with preeclampsia at 30 weeks. 1+ pitting edema in the lower extremities is common in pregnancy, especially in the third trimester, and may not be a significant finding in isolation. A mild headache can be a common symptom in pregnancy and may not be indicative of worsening preeclampsia unless accompanied by other concerning signs.
What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?
- A. Apply hydrocolloid dressing
- B. Provide wound debridement
- C. Change the dressing daily
- D. Elevate the affected area
Correct Answer: A
Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.
A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis?
- A. Glomerular filtration rate of 14 mL/min
- B. BUN 16 mg/dL
- C. Serum magnesium 1.8 mg/dL
- D. Serum phosphorus 4.0 mg/dL
Correct Answer: A
Rationale: A glomerular filtration rate (GFR) of 14 mL/min is significantly low, indicating poor kidney function and the need for hemodialysis to remove waste products effectively. BUN, serum magnesium, and serum phosphorus levels are important in assessing kidney function and electrolyte balance but are not direct indicators for the initiation of hemodialysis. BUN (blood urea nitrogen) reflects the kidney's ability to filter waste products, serum magnesium levels are important for muscle and nerve function, and serum phosphorus levels are vital for bone health.