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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?

A.

Administer the antibiotic earlier than scheduled.

B.

Administer pain medication.

C.

Have the client use the incentive spirometer.

D.

Change the dressing over the wound.

Answer and Explanation

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.


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Related Questions

Correct Answer is A

Explanation

Antacids work by raising the pH level in the stomach, which means they make the stomach less acidic. This helps to reduce the symptoms of heartburn associated with gastroesophageal reflux disease (GERD). By increasing the pH, antacids help to neutralize the excess stomach acid that can cause irritation of the esophagus and lead to heartburn. However, it's important to note that antacids provide temporary relief and do not treat the underlying cause of GERD.

Correct Answer is ["C","D","E"]

Explanation

The nurse explains that immobilizing a fracture will:

  • Help align the bone fragments and reduce movement, which is crucial for proper healing. Immobilization can help maintain the stability of the fracture site, allowing the bones to knit together and heal.
  • Help to minimize movement and subsequent pain. It provides support and reduces stress on the injured area, which can help alleviate discomfort and promote a more comfortable healing process.
  • Help to minimize movement and reduce the risk of fat globules from bone marrow entering the bloodstream and causing a fat embolism, a potentially serious complication.

Preventing blood clots, preventing malignant hyperthermia, and immobilizing a fracture are not directly related. Preventing blood clots typically involves other measures such as early mobilization, elevation, and medication to prevent deep vein thrombosis. Malignant hyperthermia is a rare, potentially life-threatening reaction to certain medications used during anesthesia, and immobilization does not directly prevent it.

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