A nurse is caring for a patient post-total hip arthroplasty. Which of the following findings requires immediate intervention?
The surgical dressing has a small amount of serosanguinous drainage.
The patient's hemoglobin dropped from 12 g/dL to 10 g/dL within 24 hours postoperatively.
The patient reports mild discomfort at the surgical site and rates pain as 4/10 on a pain scale.
The surgical extremity is cool to touch, pale, with weak pedal pulses compared to the contralateral limb.
The Correct Answer is D
A. The surgical dressing has a small amount of serosanguinous drainage. Light serosanguinous drainage is expected postoperatively and does not require immediate intervention.
B. The patient’s hemoglobin dropped from 12 g/dL to 10 g/dL within 24 hours postoperatively. A mild drop in hemoglobin postoperatively is expected due to blood loss during surgery. This does not require immediate intervention.
C. The patient reports mild discomfort at the surgical site and rates pain as 4/10 on a pain scale. Mild discomfort is expected and can be managed with prescribed analgesics.
D. The surgical extremity is cool to touch, pale, with weak pedal pulses compared to the contralateral limb. These findings indicate impaired circulation or vascular compromise, which could suggest compartment syndrome or arterial occlusion. Immediate intervention is required to prevent limb ischemia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Poor personal hygiene. SJS is not caused by poor hygiene. It is a severe hypersensitivity reaction, most often triggered by medications or infections.
B. A family history of autoimmune disorders. While some autoimmune conditions may predispose individuals to skin disorders, SJS is primarily a reaction to medications or infections rather than an inherited autoimmune condition.
C. Chronic sun exposure. Chronic sun exposure is associated with conditions like actinic keratosis and skin cancers, not SJS.
D. A recent course of antibiotics. Medications, especially antibiotics (e.g., sulfonamides), anticonvulsants, and NSAIDs, are the most common triggers of SJS. This severe reaction results in widespread skin detachment and mucosal involvement.
Correct Answer is C
Explanation
A. Encourage the patient to cross their legs while dressing to reduce strain on the hip joint: Crossing the legs after hip surgery increases the risk of hip dislocation by placing excessive stress on the hip joint. This is incorrect and unsafe.
B. Allow the patient to continue dressing independently to promote mobility: While encouraging independence is important, allowing the patient to continue this action violates hip precautions (no bending past 90°). The patient must be stopped to prevent complications.
C. Stop the patient immediately and reinforce hip precautions, advising against hip flexion greater than 90 degrees. After THA, the hip should not be flexed more than 90° as this can cause hip dislocation. The nurse should stop the patient immediately and educate them on proper dressing techniques.
D. Instruct the patient to bend forward slowly and use both hands to pull up the socks. Bending forward, even slowly, violates hip precautions and increases the risk of dislocation. The patient should use adaptive devices, such as a sock aid, instead.
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