A client 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?
Administer pain medication as ordered
Assess the client for signs and symptoms of systemic infection
Assess the surgical site and the affected extremity
Reassure the client that pain is a direct result of increased activity
Notify the surgeon immediately
The Correct Answer is C
Choice A reason: Administering pain medication as ordered is not the best action, as it does not address the cause of the new onset of pain. The nurse should first assess the client and the surgical site to rule out any complications or problems that may require immediate intervention.
Choice B reason: Assessing the client for signs and symptoms of systemic infection is not the best action, as it is not the most likely cause of the new onset of pain. Systemic infection would manifest with fever, chills, malaise, or leukocytosis, which are not mentioned in the scenario. The nurse should focus on the local signs and symptoms of the surgical site and the affected extremity.
Choice C reason: Assessing the surgical site and the affected extremity is the best action, as it allows the nurse to identify any potential complications or problems that may explain the new onset of pain. The nurse should look for signs of infection, inflammation, bleeding, hematoma, or dislocation of the hip prosthesis, such as redness, swelling, warmth, drainage, bruising, or deformity.
Choice D reason: Reassuring the client that pain is a direct result of increased activity is not the best action, as it may dismiss the client's concern and delay the detection of any serious complications or problems. The nurse should not assume that the pain is normal or expected, but rather investigate the cause and severity of the pain.
Choice E reason: Notifying the surgeon immediately is not the best action, as it is premature and unnecessary without first assessing the client and the surgical site. The nurse should gather relevant data and information before contacting the surgeon, unless there is an obvious or urgent problem that requires immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Staphylococcus aureus is the most common pathogen to cause osteomyelitis, as it is a gram-positive bacterium that can invade the bone through the bloodstream, a wound, or a surgical site. It can cause acute or chronic inflammation and infection of the bone and bone marrow.
Choice B reason: Escherichia coli is not the most common pathogen to cause osteomyelitis, as it is a gram-negative bacterium that is usually found in the gastrointestinal tract. It can cause urinary tract infections, diarrhea, or sepsis, but it is not a frequent cause of bone infections.
Choice C reason: Proteus mirabilis is not the most common pathogen to cause osteomyelitis, as it is a gram-negative bacterium that is usually found in the urinary tract. It can cause urinary tract infections, kidney stones, or septicemia, but it is not a common cause of bone infections.
Choice D reason: Pseudomonas aeruginosa is not the most common pathogen to cause osteomyelitis, as it is a gram-negative bacterium that is usually found in moist environments. It can cause skin infections, pneumonia, or septic shock, but it is not a frequent cause of bone infections.
Choice E reason: None of the above is not a correct choice, as there is one option that matches the most common pathogen to cause osteomyelitis.
Correct Answer is C
Explanation
Choice A reason: Diet is not a priority assessment for a client with osteoarthritis, as it is not a direct cause or consequence of the condition. However, diet may play a role in the management of osteoarthritis, as it can affect the body weight, inflammation, and nutrition of the client.
Choice B reason: Skin surrounding the affected joint is not a priority assessment for a client with osteoarthritis, as it is not a common or serious complication of the condition. However, skin may be affected by the use of heat or cold therapy, topical medications, or joint braces, which may cause irritation, dryness, or infection.
Choice C reason: Pain is a priority assessment for a client with osteoarthritis, as it is the main symptom and the most distressing aspect of the condition. Pain can affect the client's quality of life, mobility, function, and mood. The nurse should assess the location, intensity, frequency, duration, and aggravating or relieving factors of the pain, and provide appropriate interventions to relieve the pain.
Choice D reason: Capillary refill of affected extremity is not a priority assessment for a client with osteoarthritis, as it is not a typical or significant finding of the condition. However, capillary refill may be affected by the circulation, temperature, or hydration of the client, which may influence the healing and recovery of the joint.
Choice E reason: Range of motion of affected joint is not a priority assessment for a client with osteoarthritis, but an important assessment to evaluate the function and mobility of the joint. Osteoarthritis can cause stiffness, swelling, and deformity of the joint, which can limit the range of motion and impair the activities of daily living. The nurse should assess the active and passive range of motion of the joint, and encourage the client to perform regular exercises to maintain the joint health.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today