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: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.
Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.
Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.
Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.
Correct Answer is E
Explanation
Choice A reason: Pain management is not a key information to include in the education plan for a client with psoriasis, as psoriasis is not usually a painful condition. It may cause itching, burning, or soreness, but these are not severe enough to require pain medication.
Choice B reason: Watching skin every hour to prevent infection is not a realistic or necessary information to include in the education plan for a client with psoriasis, as psoriasis is not an infectious condition. It is an autoimmune disorder that causes the skin cells to grow faster than normal, resulting in thick, scaly, red patches on the skin.
Choice C reason: Avoiding public places until symptoms subside is not a helpful or appropriate information to include in the education plan for a client with psoriasis, as psoriasis is not a contagious condition. It does not pose a risk to others, and isolating oneself may worsen the client's mental and emotional health.
Choice D reason: Antifungal ointment will not be part of the long-term management for a client with psoriasis, as psoriasis is not a fungal infection. It is an immune-mediated condition that requires different types of treatments, such as topical steroids, vitamin D analogues, phototherapy, or biologics.
Choice E reason: Moisturizing skin regularly and avoiding triggers is a correct information to include in the education plan for a client with psoriasis, as it helps to reduce the dryness, scaling, and inflammation of the skin. Triggers may vary from person to person, but some common ones are stress, infections, cold weather, alcohol, smoking, or certain medications.
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