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A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse's best action?
- A. Administer pain medication as ordered.
- B. Assess the surgical site and the affected extremity.
- C. Reassure the patient that pain is a direct result of increased activity.
- D. Assess the patient for signs and symptoms of systemic infection.
Correct Answer: B
Rationale: Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication do not address the cause of the pain. Sudden severe pain is not considered normal after hip replacement. Sudden pain is rarely indicative of a systemic infection.
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A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient?
- A. Keep the patient's hips in abduction at all times.
- B. Keep hips flexed at no less than 90 degrees.
- C. Elevate the head of the bed to high Fowler's.
- D. Seat the patient in a low chair as soon as possible.
Correct Answer: A
Rationale: The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The patient's hips should be higher than the knees; as such, high seat chairs should be used.
A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge?
- A. Patient is able to perform ADLs independently.
- B. Patient is able to perform transfers safely.
- C. Patient is able to weight-bear equally on both legs.
- D. Patient is able to demonstrate full ROM of the affected hip.
Correct Answer: B
Rationale: The patient must be able to perform transfers and to use mobility aids safely. Each of the other listed goals is unrealistic for the patient who has undergone recent hip replacement.
The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?
- A. Knots in the rope should not be resting against pulleys.
- B. Weights should rest against the bed rails.
- C. The end of the limb in traction should be braced by the footboard of the bed.
- D. Skeletal traction may be removed for brief periods to facilitate the patient's independence.
Correct Answer: A
Rationale: Knots in the rope should not rest against pulleys, because this interferes with traction. Weights are used to apply the vector of force necessary to achieve effective traction and should hang freely at all times. To avoid interrupting traction, the limb in traction should not rest against anything. Skeletal traction is never interrupted.
A nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the patient may have a peroneal nerve injury?
- A. Numbness and burning of the foot
- B. Pallor to the dorsal surface of the foot
- C. Visible cyanosis in the toes
- D. Inadequate capillary refill to the toes
Correct Answer: A
Rationale: Peroneal nerve injury may result in numbness, tingling, and burning in the feet. Cyanosis, pallor, and decreased capillary refill are signs of inadequate circulation.
A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patient's plan of care. What intervention is most justified in the care of this patient?
- A. Administration of prophylactic antibiotics
- B. Total parenteral nutrition (TPN)
- C. Use of a pressure-relieving mattress
- D. Use of a Foley catheter until discharge
Correct Answer: C
Rationale: Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure.