A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

Choice A reason:

Assessing the surgical dressing is crucial to monitor for signs of bleeding, infection, or other complications at the surgical site. The nurse should check the dressing for any excessive drainage, unusual color, or odor, which could indicate an infection or other issues. Ensuring the dressing is intact and clean helps in preventing wound contamination and promotes healing. This assessment is vital in the immediate postoperative period to detect any early signs of complications that may require prompt intervention.

Choice B reason:

Obtaining the vital signs is a fundamental assessment that provides critical information about the patient’s overall physiological status. Vital signs include blood pressure, heart rate, respiratory rate, and temperature. These measurements help in identifying any deviations from the normal ranges that could indicate complications such as hypovolemia, infection, or respiratory distress. Regular monitoring of vital signs allows the nurse to detect and respond to any changes in the patient’s condition promptly. Normal ranges for adults are typically: blood pressure 120/80 mmHg, heart rate 60-100 beats per minute, respiratory rate 12-20 breaths per minute, and temperature around 98.6°F (37°C).

Choice C reason:

Assessing the pain level is essential for effective pain management and patient comfort. Postoperative pain can significantly impact a patient’s recovery and ability to participate in necessary activities such as deep breathing and ambulation. The nurse should use a standardized pain assessment tool, such as the Numeric Rating Scale (0-10), to evaluate the patient’s pain intensity and quality. Effective pain management involves administering prescribed analgesics and evaluating their effectiveness, as well as implementing non-pharmacological interventions as needed. Proper pain control helps in reducing stress, promoting healing, and improving the overall recovery experience.

Choice D reason:

Assessing the respiratory rate and effort is critical to ensure that the patient is breathing adequately and not experiencing respiratory distress. Anesthesia and surgery can affect respiratory function, making it essential to monitor for signs of hypoxia, such as increased respiratory rate, use of accessory muscles, or cyanosis. The nurse should observe the patient’s breathing pattern, listen to breath sounds, and measure oxygen saturation levels using a pulse oximeter. Normal oxygen saturation levels are typically between 95-100%. Prompt identification and management of respiratory issues are crucial to prevent complications such as atelectasis and pneumonia.

Choice E reason:

Asking the patient if they have a ride home is not a priority assessment in the immediate postoperative period. While discharge planning is important, the primary focus should be on stabilizing the patient’s physiological status and addressing any immediate postoperative needs. Ensuring the patient has a ride home can be addressed later in the recovery process, once the patient is stable and ready for discharge. The initial assessments should prioritize monitoring for complications and ensuring the patient’s safety and comfort.

Choice A: Collect patient information

This is the first step in the nursing process, known as the assessment phase. During this phase, the nurse gathers comprehensive information about the patient’s health status, including medical history, physical examination findings, and any relevant diagnostic test results. This information forms the foundation for identifying the patient’s health needs and planning appropriate care.

Choice B: Identify any clinical problems

The second step is the diagnosis phase, where the nurse analyzes the collected data to identify the patient’s health problems. These problems can be actual or potential issues that require nursing intervention. Accurate identification of clinical problems is crucial for developing an effective care plan.

Choice C: Decide a plan of action

The third step is the planning phase. In this phase, the nurse sets measurable and achievable goals for the patient’s care and decides on the appropriate nursing interventions to address the identified clinical problems. The plan of action should be individualized to meet the specific needs of the patient.

Choice D: Carry out the plan

The fourth step is the implementation phase, where the nurse executes the planned interventions. This may involve administering medications, providing education, performing procedures, or coordinating with other healthcare professionals. The goal is to achieve the desired patient outcomes as outlined in the care plan.

Choice E: Determine whether the plan was effective

The final step is the evaluation phase. In this phase, the nurse assesses the patient’s response to the implemented interventions and determines whether the goals of the care plan have been met. If the desired outcomes are not achieved, the nurse may need to revise the care plan and repeat the process.