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The nurse is caring for an older adult following a total hip arthroplasty. The nurse should anticipate a prescription for which postoperative medication?
- A. Hydrocortisone
- B. Enoxaparin
- C. Metoprolol
- D. Furosemide
- E. Morphine
Correct Answer: B,E
Rationale: Enoxaparin prevents venous thromboembolism, a common risk post-hip arthroplasty, and morphine manages postoperative pain. Hydrocortisone, metoprolol, and furosemide are not routinely prescribed unless indicated by specific conditions.
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The nurse is caring for an older adult following a total hip arthroplasty. The nurse should anticipate a prescription for which postoperative medication?
- A. Hydrocortisone
- B. Enoxaparin
- C. Metoprolol
- D. Furosemide
- E. Morphine
Correct Answer: B,E
Rationale: Enoxaparin prevents venous thromboembolism, a common risk post-hip arthroplasty, and morphine manages postoperative pain. Hydrocortisone, metoprolol, and furosemide are not routinely prescribed unless indicated by specific conditions.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
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• Nurses' Notes
0920: Client presents for a follow-up visit. Client reports increased difficulty with activities of daily living because of dyspnea. Reports pain and swelling in both lower extremities that increases with movement. "Washing my hair now takes me an hour instead of fifteen minutes." Transverse surgical incision was pink, approximated, and crusted—9 inches in length. Two Jackson-Pratt drains contained a total of 15 mL of serumlike drainage. Incisional pain reported at a '4' on the Numerical Rating Scale. Endorses increased incisional pain while coughing. The client reports full adherence to postoperative enoxaparin self-injections. She reports ejecting the air bubble prior to injection. Reports relief with prescribed oxycodone-acetaminophen but experiences generalized itching and drowsiness after.
• Medical History
• gastric bypass surgery performed two years ago
• dyslipidemia
• diabetes mellitus (type two)
• Vital Signs
• T 99.0°F (37.2°C); HR 90 beats/min; RR 18 breaths/min; BP 119/67 mm Hg; Pulse oximetry 96% on room air.
The nurse in the medical office is caring for a 41-year-old client who is 2-week postoperative abdominoplasty. Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. wound assessment findings
- B. tolerance with activities of daily living
- C. pain in lower extremities
- D. enoxaparin self-injections
- E. pulse, respirations, and blood pressure
Correct Answer: B,C,D
Rationale: Tolerance with activities of daily living. The client reports increased difficulty with activities of daily living (ADLs) due to dyspnea, which could indicate a significant complication, such as pulmonary embolism (PE). Dyspnea, especially in the postoperative period, should always be investigated promptly, as it could be a sign of a PE, which is a life-threatening emergency. Immediate follow-up is necessary to rule out PE or other respiratory or circulatory issues. Pain in lower extremities. Pain and swelling in the lower extremities that increase with movement could suggest deep vein thrombosis (DVT). This complication is especially concerning in a postoperative patient on anticoagulation therapy (enoxaparin). DVT can lead to pulmonary embolism if the clot dislodges, which could cause dyspnea. This requires immediate follow-up to assess for DVT and initiate treatment if necessary. The client reports full adherence to postoperative enoxaparin self-injections and mentions ejecting the air bubble before injection. This is an incorrect technique; ejecting the air bubble can result in an underdose of the medication, potentially leading to ineffective anticoagulation. This can increase the risk of complications like DVT or VTE. Correct technique is crucial to ensure proper dosing. Immediate follow-up is required to educate the client about appropriate injection techniques (not ejecting the air bubble) to prevent these risks.Wound assessment findings. The transverse surgical incision is described as pink, approximated, and crusted, which are normal findings in the early postoperative period. These findings suggest no signs of infection or delayed wound healing. Therefore, no immediate follow-up is required for this finding.Incision pain level and characteristics. The client reports incisional pain at a level of 4 on the Numerical Rating Scale and increased pain when coughing. This level of pain is within a manageable range for a postoperative patient. The description of the pain as incisional and aggravated by coughing is consistent with expected postoperative discomfort. The pain level is manageable, and this is not a priority concern for immediate follow-up unless it becomes severe or is associated with other complications (e.g., infection or dehiscence).
The nurse is conducting an in-service for nursing students. It would be appropriate for the nurse to state which of the following procedures requires a sterile technique? Select all that apply.
- A. Changing the dressing for a central line
- B. Inserting an indwelling urinary catheter
- C. Removing a peripheral vascular access device
- D. Suctioning an endotracheal tube with in-line suction
- E. Inserting a nasogastric tube (NGT)
Correct Answer: A,B,D
Rationale: Sterile technique is required for central line dressing changes, indwelling urinary catheter insertion, and endotracheal suctioning due to the risk of introducing pathogens into sterile areas.
The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply.
- A. A client who had rectal surgery and a post-operative abscess
- B. A child who has pneumonia
- C. An older client who is post-myocardial infarction (MI)
- D. A teenager with leukemia, a neutrophil count of 500/microliter, and is receiving erythropoietin for anemia
- E. An adult patient with acute pancreatitis and has disseminated intravascular coagulation (DIC)
Correct Answer: A,D,E
Rationale: Rectal temperature is contraindicated in rectal surgery/abscess (due to trauma risk), neutropenia (infection risk), and DIC (bleeding risk). Pneumonia and post-MI do not contraindicate rectal measurement.