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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Institute of Medicine (IOM) research is not a method for developing procedures, but an organization that conducts health-related studies and provides recommendations for improving health care quality and safety.

Choice B reason: Evidence-based practice is the correct method for developing procedures. It is the process of integrating the best available research evidence with clinical expertise and patient preferences to make decisions about health care.

Choice C reason: Knowledge, skills, and attitude are not a method for developing procedures, but the components of competency that nurses need to provide safe and effective care.

Choice D reason: Core measures are not a method for developing procedures, but a set of standardized performance indicators that evaluate the quality of care for specific conditions or procedures.

A. Include an average daily intake of 300 mg of calcium B. Walk 20-30 minutes three days a week C. Engage in isometric exercise 20-30 minutes weekly D. Include adequate intake of vitamin E E. None of the above

Correct Answer is E

Explanation

Choice A reason: Including an average daily intake of 300 mg of calcium is not a sufficient measure to prevent osteoporosis, as it is below the recommended dietary allowance (RDA) for calcium, which is 1000 mg for adults aged 19-50 years, and 1200 mg for adults aged 51 years and older. Calcium is an essential mineral for bone health, as it helps to build and maintain the bone density and strength.

Choice B reason: Walking 20-30 minutes three days a week is not an optimal measure to prevent osteoporosis, as it is below the recommended physical activity guidelines, which suggest at least 150 minutes of moderate-intensity aerobic exercise per week, and at least two sessions of muscle-strengthening activities per week. Physical activity is beneficial for bone health, as it stimulates the bone formation and reduces the bone loss.

Choice C reason: Engaging in isometric exercise 20-30 minutes weekly is not an effective measure to prevent osteoporosis, as it is not the best type of exercise for bone health, and it is not performed frequently enough. Isometric exercise is a form of exercise that involves contracting the muscles without moving the joints, such as holding a plank or a wall sit. Isometric exercise does not provide enough mechanical stress or load to the bones, which is needed to stimulate the bone remodeling and growth.

Choice D reason: Including adequate intake of vitamin E is not a relevant measure to prevent osteoporosis, as it is not a major nutrient for bone health, and it has no direct effect on the bone metabolism. Vitamin E is an antioxidant that helps to protect the cells from oxidative stress and inflammation, which may have some indirect benefits for the bone health, but it is not a key factor. Vitamin E is also not a common deficiency, and it can be obtained from various foods, such as vegetable oils, nuts, seeds, and green leafy vegetables.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which should the nurse include when instructing a client on the prevention of osteoporosis?

Correct Answer is E

Explanation

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