A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

"You should use an incentive spirometer every 8 hours."

"Clean the incision daily with hydrogen peroxide."

"You can cross your legs at the ankles when sitting down."

"Install a raised toilet seat in your bathroom."

Answer and Explanation

The Correct Answer is D

Rationale:

A. "You should use an incentive spirometer every 8 hours." Using an incentive spirometer is important for preventing respiratory complications, but the recommendation should be to use it every 1-2 hours while awake, not just every 8 hours.

B. "Clean the incision daily with hydrogen peroxide." Hydrogen peroxide is too harsh for wound care and can delay healing by damaging new tissue. The incision should be cleaned with mild soap and water or as directed by the healthcare provider.

C. "You can cross your legs at the ankles when sitting down." After a hip replacement, clients should avoid crossing their legs, especially at the knees, to prevent dislocation of the new hip joint.

D. "Install a raised toilet seat in your bathroom." After hip replacement surgery, the client should avoid bending the hip beyond 90 degrees to reduce the risk of dislocation. Installing a raised toilet seat helps the client maintain proper positioning and avoid hip flexion beyond the recommended limit.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

Rationale:

Skin turgor: In DKA, dehydration is a common result due to fluid loss from excessive urination and hyperglycemia. Decreased skin turgor, or slight tenting, is an indicator of dehydration. HHS is characterized by severe hyperglycemia and profound dehydration, leading to significant fluid deficits and impaired skin turgor.
Blood glucose greater than expected reference range: Both DKA and HHS present with elevated blood glucose levels. The client's blood glucose level of 468 mg/dL is higher than the expected range. However, blood glucose levels tend to be much higher in HHS, sometimes exceeding 1000 mg/dL, while DKA usually ranges between 250–600 mg/dL.
Blood pH: A blood pH of 7.30 is low and indicative of acidosis, which is a hallmark of DKA. In DKA, the body produces ketones as a byproduct of fat metabolism, which causes the blood pH to drop, leading to metabolic acidosis. HHS typically does not cause significant acidosis, and pH is generally within normal limits.
Creatinine greater than expected reference range: Elevated creatinine levels suggest kidney impairment, which is common in DKA and HHS due to severe dehydration and osmotic diuresis. Dehydration significantly impairs renal perfusion and function, leading to elevated creatinine and BUN levels.
Urine ketones: Ketones form when the body starts breaking down fat for energy due to a lack of insulin, which is characteristic of DKA. In HHS, the body does not typically produce significant amounts of ketones, as some insulin is still present and inhibiting fat metabolism.

A. Cardiac findings B. Neurologic assessment C. Temperature D. Respiratory characteristics E. Urinalysis F. Cardiac rhythm. G. Breath Sounds H. Bowel sounds I. Respiratory rate

Correct Answer is ["A","C","D","E","G","I"]

Explanation

Rationale for Correct Choices:

A. Cardiac findings: The client has signs of fluid retention, including jugular vein distention (JVD) and periorbital edema, suggesting potential heart failure. Monitoring the heart and assessing for potential complications such as arrhythmias or decreased cardiac output is necessary.

B. Neurologic assessment: The client is alert and oriented to person, place, and time, with no signs of confusion or altered mental status. Neurological assessment does not need to be prioritized at this time.

C. Temperature: The elevated temperature of 38.8°C (101.8°F) could indicate an underlying infection. Given the client's recent history of strep throat and the signs of infection in the urine (positive nitrites and leukocyte esterase), a urinary tract infection (UTI) could be a potential cause for the fever.

D. Respiratory characteristics: The client has crackles bilaterally, labored breathing, and low oxygen saturation (90% on room air), which suggest respiratory distress. These findings need further follow-up.

E. Urinalysis: The urinalysis shows dark red color (indicative of hematuria), positive nitrites, positive leukocyte esterase, and blood in the urine. These results suggest a urinary tract infection (UTI) and possible kidney involvement. The reddish-brown urine may also require further assessment to rule out hemolysis or muscle injury.

F. Cardiac rhythm: The client’s heart rhythm is described as normal sinus rhythm (NSR) with a rate of 88/min. There are no immediate concerns about arrhythmias at this time, and the heart rate is within normal limits.

G. Breath sounds: The presence of crackles on auscultation in both lungs indicates possible pulmonary edema or fluid overload, which is commonly seen in heart failure. Follow-up is required to assess for worsening respiratory status and need for intervention.

H. Bowel sounds: The client's bowel sounds are normal, with no signs of gastrointestinal distress or obstruction. There is no indication of a problem in the GI system.

I. Respiratory rate: The client's respiratory rate is 26/min, which is elevated. This, combined with shortness of breath and labored respirations, indicates significant respiratory distress. It is a key indicator of impaired gas exchange or increased work of breathing.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department. Exhibits For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

The nurse is caring for a client in the emergency department. Exhibits Identify the findings that require follow-up. Select all that apply.

Correct Answer is ["A","C","D","E","G","I"]

Explanation

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client’s dropdown followed by the client's dropdown.

A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of respiratory failure?

A nurse is teaching a group of clients who have cancer about radiation therapy. Which of the following activities should the nurse include in the teaching?

A nurse is teaching a client who is to begin chemotherapy about a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include in the teaching?

A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?

A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?