The medical-surgical nurse is caring for a client postoperatively after a total hip arthroplasty. The nurse is calculating the client's intake and output and notes a total of 100 mL of sanguineous drainage out of the hip drain in the 24 hours since surgery. What is the most appropriate action for the nurse to take?

Remove the drain

Continue to assess and monitor intake and output every shift

Elevate affected leg and place client in Trendelenburg position

Notify the surgeon and make aware of this finding

None of the above

Answer and Explanation

The Correct Answer is B

Choice A reason: Removing the drain is not an appropriate action for the nurse to take, as it may cause bleeding, infection, or hematoma at the surgical site. The drain is placed to prevent the accumulation of fluid and blood in the hip joint, and it should be removed only by the surgeon when the drainage is minimal and the wound is healing.

Choice B reason: Continuing to assess and monitor intake and output every shift is an appropriate action for the nurse to take, as it helps to evaluate the fluid balance and the renal function of the client. The nurse should record the amount, color, and consistency of the drainage, and compare it with the previous measurements. The nurse should also monitor the vital signs, the hemoglobin and hematocrit levels, and the signs of dehydration or fluid overload.

Choice C reason: Elevating the affected leg and placing the client in Trendelenburg position is not an appropriate action for the nurse to take, as it may cause hip dislocation, hypotension, or respiratory distress. The nurse should keep the affected leg slightly abducted and aligned with the body, and avoid flexing the hip more than 90 degrees. The nurse should also maintain the client in a semi-Fowler's or supine position, and avoid turning the client to the affected side.

Choice D reason: Notifying the surgeon and making aware of this finding is not an appropriate action for the nurse to take, as it is not an urgent or abnormal situation. The nurse should report the drainage to the surgeon only if it exceeds the expected amount, which is usually less than 200 mL in the first 24 hours after surgery, or if it changes in color, consistency, or odor.

Choice E reason: None of the above is not a correct choice, as there is one option that matches the most appropriate action for the nurse to take.

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Correct Answer is C

Explanation

Choice A reason: Transferring from sitting to standing position is not a high-risk activity for hip dislocation, as long as the client follows the proper precautions, such as keeping the operated leg slightly forward, using a chair with armrests, and avoiding twisting or pivoting the hip.

Choice B reason: Straining during a bowel movement is not a direct risk factor for hip dislocation, but it may cause constipation, which is a common problem after surgery. The nurse should educate the client on the importance of adequate hydration, fiber intake, and stool softeners to prevent constipation and reduce the need for straining.

Choice C reason: Bending down to put socks on is a risky activity for hip dislocation, as it violates the hip precautions of avoiding flexing the hip more than 90 degrees, adducting the hip, or internally rotating the hip. The nurse should instruct the client to use assistive devices, such as a sock aid or a long-handled reacher, to put on socks or shoes without bending the hip.

Choice D reason: Turning in bed with an abductor pillow in place is a safe activity for hip dislocation, as the abductor pillow helps to maintain the alignment and stability of the hip joint. The nurse should teach the client to use the abductor pillow while in bed for the first few weeks after surgery, and to turn from side to side with the assistance of a caregiver.

Choice E reason: Crossing the legs or ankles is a dangerous activity for hip dislocation, as it causes the hip to move out of its normal position. The nurse should remind the client to keep the legs apart at all times, and to use a pillow or a wedge between the legs when lying on the side.

A. Diet B. Skin surrounding the affected joint C. Pain D. Capillary refill of affected extremity E. Range of motion of affected joint

Correct Answer is C

Explanation

Choice A reason: Diet is not a priority assessment for a client with osteoarthritis, as it is not a direct cause or consequence of the condition. However, diet may play a role in the management of osteoarthritis, as it can affect the body weight, inflammation, and nutrition of the client.

Choice B reason: Skin surrounding the affected joint is not a priority assessment for a client with osteoarthritis, as it is not a common or serious complication of the condition. However, skin may be affected by the use of heat or cold therapy, topical medications, or joint braces, which may cause irritation, dryness, or infection.

Choice C reason: Pain is a priority assessment for a client with osteoarthritis, as it is the main symptom and the most distressing aspect of the condition. Pain can affect the client's quality of life, mobility, function, and mood. The nurse should assess the location, intensity, frequency, duration, and aggravating or relieving factors of the pain, and provide appropriate interventions to relieve the pain.

Choice D reason: Capillary refill of affected extremity is not a priority assessment for a client with osteoarthritis, as it is not a typical or significant finding of the condition. However, capillary refill may be affected by the circulation, temperature, or hydration of the client, which may influence the healing and recovery of the joint.

Choice E reason: Range of motion of affected joint is not a priority assessment for a client with osteoarthritis, but an important assessment to evaluate the function and mobility of the joint. Osteoarthritis can cause stiffness, swelling, and deformity of the joint, which can limit the range of motion and impair the activities of daily living. The nurse should assess the active and passive range of motion of the joint, and encourage the client to perform regular exercises to maintain the joint health.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation?

Correct Answer is C

Explanation

The nurse would prioritize which assessment for a client with a new diagnosis of osteoarthritis?

Correct Answer is C

Explanation

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The registered nurse is planning the client assignments for the day. What is the most appropriate assignment for Unlicensed Assistive Personnel (UAP)?

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