How it Works
Try Naxlex NCLEX-RN (Free-Trial)

An older adult client with no cognitive impairment had a left hip arthroplasty 72 hours ago and is now confused and lethargic. Which action should the nurse implement?

A.

Auscultate for bowel sounds.

B.

Compare pedal pulses bilaterally.

C.

Observe the surgical incision.

D.

Assess mobility of the right leg.

Answer and Explanation

The Correct Answer is B

A. Auscultate for bowel sounds. While monitoring for postoperative ileus is important, it is not the priority intervention in a patient who is suddenly confused and lethargic after hip surgery. Avascular complications, fat embolism, or deep vein thrombosis (DVT) are more immediate concerns.
B. Compare pedal pulses bilaterally. A sudden change in mental status after hip arthroplasty could indicate a fat embolism or deep vein thrombosis (DVT) leading to pulmonary embolism. Comparing bilateral pedal pulses helps assess for signs of vascular impairment or embolic complications, which are serious postoperative risks. Fat embolism syndrome (FES) can cause confusion, lethargy, and respiratory distress, requiring immediate intervention.
C. Observe the surgical incision. While assessing for infection or bleeding is important, these complications do not typically cause sudden confusion and lethargy. Systemic embolic events or impaired circulation are more critical to assess first.
D. Assess mobility of the right leg. Evaluating mobility is part of routine post-arthroplasty care, but it does not directly address the sudden mental status changes seen in this patient. Assessing circulation and embolic risk takes priority.


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

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Rationale:

  1. Calculate total fat calories for each day:
    • Day 1: 24×38=91224 \times 38 = 912 kJ
    • Day 2: 22×38=83622 \times 38 = 836 kJ
    • Day 3: 23×38=87423 \times 38 = 874 kJ
  2. Convert total daily calories to kJ:
    • Day 1: 3,200×4.184=13,388.83,200 \times 4.184 = 13,388.8 kJ
    • Day 2: 2,980×4.184=12,471.32,980 \times 4.184 = 12,471.3 kJ
    • Day 3: 3,310×4.184=13,841.03,310 \times 4.184 = 13,841.0 kJ
  3. Calculate fat percentage:
    • Day 1: (912/13388.8)×100=18.2%
    • Day 2: (836/12471.3)×100=17.1%
    • Day 3: (874/13841.0)×100=17.3%

Average fat percentage: (18.2+17.1+17.3)/3=17.5%

  1. Interpretation:
    • The recommended fat intake range is 20-35% of total calories.
    • The client's fat intake is 14-19%, which is below the recommended range.
    • The client should increase his fat intake to meet nutritional needs.

Correct Answer is B

Explanation

A. Peripheral neurovascular dysfunction. While some chemotherapy agents can cause neuropathy, the immediate risk of a vesicant (a drug that can cause severe tissue damage if it leaks) is extravasation, leading to skin and tissue damage, rather than direct neurovascular impairment.
B. Impaired skin integrity. Vesicants can cause severe tissue necrosis if they extravasate (leak into surrounding tissues). Leaving an IV in place for 72 hours increases the risk of infiltration or extravasation, which can lead to serious complications, including blistering, necrosis, and deep tissue injury. Proper IV site rotation and monitoring are essential to prevent skin and tissue damage.
C. Fluid volume excess. Fluid volume excess is not a direct risk related to vesicant chemotherapy. While some IV fluids can contribute to fluid overload, the primary concern with vesicants is extravasation and tissue damage.
D. Acute pain and anxiety. While pain and anxiety can occur if extravasation happens, the greatest clinical risk is the physical damage caused by tissue necrosis. Pain is a symptom of extravasation, but preventing skin and tissue injury is the priority.

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

Register