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?
Auscultate for bowel sounds.
Compare pedal pulses bilaterally.
Observe the surgical incision.
Assess mobility of the right leg.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["42"]
Explanation
Flowrate(gtt/min) = (Total volume×Drop factor)/Total time
= (500×20)/240
= 1000/240
= 41.67, round off to the nearest whole number
= 42
Thus, the nurse should regulate the infusion at 42 gtt/min.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Rationale:
- 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
- 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
- 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%
- 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.
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