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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Scabies can be cured with prescription medications that kill the mites and their eggs, such as permethrin cream or ivermectin pills. Steroid cream may help to reduce the itching and inflammation, but it does not eliminate the infection.
Choice B reason: Treatment should start as soon as possible after the diagnosis of scabies, but there is no specific time limit of 72 hours. The sooner the treatment begins, the faster the symptoms will improve and the risk of transmission will decrease.
Choice C reason: Washing clothes, towels, and sheets in hot water is an important part of the education for a client with scabies, as it helps to get rid of any mites or eggs that may have been transferred to the fabrics. The items should also be dried in a hot dryer or sealed in a plastic bag for at least 72 hours.
Choice D reason: Reducing intake of refined sugar has no effect on the risk of scabies, as scabies is not caused by dietary factors, but by a parasitic infestation of the skin by the Sarcoptes scabiei mite. The mite is transmitted by direct skin-to-skin contact or by sharing personal items with an infected person.
Choice E reason: Avoiding close contact with others until treated is another key part of the education for a client with scabies, as it helps to prevent the spread of the infection to other people. The client should also inform their household members, sexual partners, and close contacts, as they may need to be treated as well.
Correct Answer is E
Explanation
Choice A reason: Pain management is not a key information to include in the education plan for a client with psoriasis, as psoriasis is not usually a painful condition. It may cause itching, burning, or soreness, but these are not severe enough to require pain medication.
Choice B reason: Watching skin every hour to prevent infection is not a realistic or necessary information to include in the education plan for a client with psoriasis, as psoriasis is not an infectious condition. It is an autoimmune disorder that causes the skin cells to grow faster than normal, resulting in thick, scaly, red patches on the skin.
Choice C reason: Avoiding public places until symptoms subside is not a helpful or appropriate information to include in the education plan for a client with psoriasis, as psoriasis is not a contagious condition. It does not pose a risk to others, and isolating oneself may worsen the client's mental and emotional health.
Choice D reason: Antifungal ointment will not be part of the long-term management for a client with psoriasis, as psoriasis is not a fungal infection. It is an immune-mediated condition that requires different types of treatments, such as topical steroids, vitamin D analogues, phototherapy, or biologics.
Choice E reason: Moisturizing skin regularly and avoiding triggers is a correct information to include in the education plan for a client with psoriasis, as it helps to reduce the dryness, scaling, and inflammation of the skin. Triggers may vary from person to person, but some common ones are stress, infections, cold weather, alcohol, smoking, or certain medications.
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