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Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected?
- A. Urine output was 160 mL in the past eight (8) hours.
- B. Paralysis and paresthesia of the right leg.
- C. T 99.0°F, P 98, R 20, and BP 100/60.
- D. Lungs are clear bilaterally in all lobes.
Correct Answer: D
Rationale: Clear lungs indicate no respiratory complications, expected post-hip replacement. Low urine output (20 mL/hr), paralysis/paresthesia, and mild hypotension suggest complications.
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The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching?
- A. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth.
- B. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion.
- C. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume.
- D. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.
Correct Answer: D
Rationale: Getting out of bed upright risks hip dislocation post-hip replacement; log-rolling is correct. Diaphragmatic breathing, foot exercises, and spirometry are appropriate.
Which statement explains the nurse's responsibility when obtaining informed consent for the client undergoing a surgical procedure?
- A. The nurse should provide detailed information about the procedure.
- B. The nurse should inform the client of any legal consultation needed.
- C. The nurse should write a list of the risks for postoperative complications.
- D. The nurse should ensure the client is voluntarily giving consent.
Correct Answer: D
Rationale: The nurse ensures voluntary consent, verifying understanding and no coercion, per ethical standards. Detailed information, legal consultation, and risk lists are the HCP’s role.
The nurse received a report the elderly postoperative client became confused during the previous shift. Which client problem would the nurse include in the plan of care?
- A. Risk for injury.
- B. Altered comfort level.
- C. Impaired circulation.
- D. Impaired skin integrity.
Correct Answer: A
Rationale: Confusion increases fall and injury risk, the priority problem in elderly postoperative clients. Comfort, circulation, and skin integrity are secondary.
The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement?
- A. Administer pain medication as soon as the time frame allows.
- B. Use nonpharmacological methods to replace medications.
- C. Use cryotherapy after heat therapy because it works faster.
- D. Instruct family members to administer medication with the PCA.
Correct Answer: A
Rationale: Administering pain medication PRN within time frames ensures timely relief, per pain management standards. Nonpharmacological methods supplement, cryotherapy timing varies, and family PCA use is unsafe.
The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first?
- A. Apply antiembolism hose to the client.
- B. Attach the drain to 20 cm suction.
- C. Assess the client's vital signs.
- D. Listen to the report from the anesthesiologist.
Correct Answer: C
Rationale: Assessing vital signs establishes a baseline post-PACU, per ABCs. Antiembolism hose, drain attachment, and anesthesiologist report follow.