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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Infection. Infection is a major concern in burn patients due to loss of skin integrity, but airway compromise is the most immediate life-threatening risk.

B. Paralytic ileus. Burn patients may develop paralytic ileus due to stress response and fluid shifts, but this is not the highest priority compared to airway obstruction.

C. Airway obstruction. Burns involving the face, neck, and chest increase the risk of airway swelling and obstruction. The nurse should assess for signs of respiratory distress, stridor, or hoarseness and be prepared for early intubation if needed.

D. Fluid imbalance. Fluid shifts can cause hypovolemia and shock, making fluid resuscitation critical. However, airway management remains the highest priority, especially in burns affecting the upper airway.

A. “I can bend my hip beyond 90 degrees as long as I feel comfortable." B. “I should avoid turning onto my operative side to prevent hip dislocation." C. “I don't need to use a pillow or abduction device between my legs when turning." D. “I should cross my legs when sitting to keep my hip stable."

Correct Answer is B

Explanation

A. “I can bend my hip beyond 90 degrees as long as I feel comfortable." Flexing the hip beyond 90 degrees increases the risk of hip dislocation.

B. “I should avoid turning onto my operative side to prevent hip dislocation." Lying on the operative side increases pressure on the hip joint and can lead to dislocation or delayed healing.

C. “I don't need to use a pillow or abduction device between my legs when turning." An abduction pillow or device is necessary to keep the legs apart and prevent hip adduction, which can lead to dislocation.

D. “I should cross my legs when sitting to keep my hip stable." Crossing the legs can cause internal rotation and hip dislocation.

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A nurse is caring for a patient post-total hip arthroplasty. Which of the following findings requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is C

Explanation

Which of the following statements by the patient is correct regarding postoperative positioning after total hip arthroplasty?

Correct Answer is B

Explanation

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