A nurse is caring for a client who is 1-day post-total hip replacement surgery. Assessment findings are as follows.
Assessment
- Vital Signs BP 112/68 mmHg
- Heart rate 75 beats/min. Respirations 18 breaths/min 02 saturation 90%, room air Surgical site clean, dry, intact
- Lung sounds clear upper lobes, diminished lower lobes.
- Pain 2/10
Which action by the nurse is most appropriate at this time?
Administer the antibiotic earlier than scheduled.
Administer pain medication.
Have the client use the incentive spirometer.
Change the dressing over the wound.
The Correct Answer is C
The assessment findings indicate that the client has diminished lung sounds in the lower lobes, suggesting potential postoperative atelectasis or decreased air movement in the lungs. Using an incentive spirometer can help improve lung expansion and prevent respiratory complications such as pneumonia. It is important to address this issue promptly to prevent further deterioration of lung function.
Administering pain medication may be necessary depending on the client's level of pain, but addressing the respiratory issue takes priority in this situation.
Administering the antibiotic earlier than scheduled or changing the dressing over the wound may not be indicated based on the provided assessment findings.
Therefore, having the client use the incentive spirometer is the most appropriate action at this time to promote optimal lung function and prevent respiratory complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Anaphylaxis is a severe and potentially life-threatening allergic reaction that can lead to a rapid drop in blood pressure, known as hypotension. This drop in blood pressure is a critical indicator of the severity of the reaction and the effectiveness of the treatment provided. The nurse needs to monitor the patient's blood pressure closely to ensure it stabilizes and returns to a safe range.
While oxygen saturation, heart rate, and orientation are also important parameters to assess, they are secondary to blood pressure in evaluating the effectiveness of treatment for anaphylaxis. Oxygen saturation can help determine the adequacy of oxygenation, heart rate can indicate the presence of tachycardia (which may be a sign of an ongoing reaction or hypoperfusion), and orientation can provide information about the patient's mental status and potential complications.
Correct Answer is B
Explanation
According to the given information, Aydan's insulin lispro (Humalog) dosage is 1 unit per 50 grams of carbohydrates eaten. As Aydan has just consumed 150 grams of carbs for lunch, we can calculate the insulin dose as follows:
Insulin dose = Carbohydrates eaten / Insulin-to-carbohydrate ratio Insulin dose = 150 grams / 50 grams/unit
Insulin dose = 3 units
Therefore, the nurse should prepare to administer 3 units of Aydan's prescribed rapid-acting insulin (Insulin lispro) to cover the carbohydrates he consumed for lunch. The long-acting insulin (Glargine) is typically given at bedtime to provide a basal insulin level and is not directly related to meal coverage.
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