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 A

Explanation

Choice A reason: This statement is incorrect and indicates the need for further education. Failure to rescue is not the ability of the nurse to save a client's life, but the inability or failure to do so. It is defined as the death of a hospitalized client who experienced a potentially preventable complication.

Choice B reason: This statement is correct and does not indicate the need for further education. Failure to rescue includes the failure of the nurse to report changes in a client's condition to the provider, which could delay the diagnosis and treatment of the complication.

Choice C reason: This statement is correct and does not indicate the need for further education. Failure to rescue is the failure to recognize a client's condition is deteriorating, which could lead to missed opportunities for intervention and prevention of adverse outcomes.

Choice D reason: This statement is correct and does not indicate the need for further education. Failure to rescue involves the lack of managing complications, which could result in increased morbidity and mortality.

A. Scabies cannot be cured, but may be controlled with steroid cream B. Treatment must start within 72 hours of symptoms C. Wash clothes, towels, and sheets in hot water D. Reducing intake of refined sugar will decrease risk of scabies E. Avoid close contact with others until treated

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing instructor is educating a group of nursing students on the nursing concept Failure to Rescue (FTR). Which statement made by a student would indicate the need for further education?

Correct Answer is A

Explanation

A client with a recent diagnosis of scabies will need what education?

Correct Answer is C

Explanation

A nurse is preparing to educate a client at risk for developing osteoporosis on the importance of increasing calcium in the diet. Which are the best foods to include in the teaching plan when educating a client on increased calcium intake?

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

The nurse is caring for a client with a fracture of the right humerus. Which assessment finding could be an early sign of a fat embolus?

A nurse is caring for a client who has a fractured hip and is in Buck's traction prior to surgical repair. What should the nurse include in the plan of care?

A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. Treatment modalities that are common to all of these musculoskeletal injuries include which of the following?

A nurse is caring for a 78-year-old obese client with a history of osteoarthritis. When planning the client's care, what goals should the nurse include?