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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Client with difficulty swallowing food and fluids who requires assistance with feeding is not an appropriate assignment for UAP. This client is at risk of aspiration and needs close monitoring and intervention by a licensed nurse.
Choice B reason: Client requiring a colostomy irrigation is not an appropriate assignment for UAP. This is a sterile procedure that involves inserting a catheter into the stoma and instilling fluid to flush out the bowel. This requires advanced skills and knowledge that are beyond the scope of practice of UAP.
Choice C reason: Client requiring vital signs immediately following open heart surgery is not an appropriate assignment for UAP. This client is in a critical condition and needs frequent and accurate assessment and evaluation by a licensed nurse.
Choice D reason: Client requiring a urine specimen collection is the most appropriate assignment for UAP. This is a routine and non-invasive task that can be delegated to UAP under the supervision of a licensed nurse.
Correct Answer is C
Explanation
Choice A reason: Scabies can be cured with prescription medications that kill the mites and their eggs, such as permethrin cream or ivermectin pills. Steroid cream may help to reduce the itching and inflammation, but it does not eliminate the infection.
Choice B reason: Treatment should start as soon as possible after the diagnosis of scabies, but there is no specific time limit of 72 hours. The sooner the treatment begins, the faster the symptoms will improve and the risk of transmission will decrease.
Choice C reason: Washing clothes, towels, and sheets in hot water is an important part of the education for a client with scabies, as it helps to get rid of any mites or eggs that may have been transferred to the fabrics. The items should also be dried in a hot dryer or sealed in a plastic bag for at least 72 hours.
Choice D reason: Reducing intake of refined sugar has no effect on the risk of scabies, as scabies is not caused by dietary factors, but by a parasitic infestation of the skin by the Sarcoptes scabiei mite. The mite is transmitted by direct skin-to-skin contact or by sharing personal items with an infected person.
Choice E reason: Avoiding close contact with others until treated is another key part of the education for a client with scabies, as it helps to prevent the spread of the infection to other people. The client should also inform their household members, sexual partners, and close contacts, as they may need to be treated as well.
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