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 D
Explanation
Choice A reason: Calcitriol (Fortica) is not the medication that will have the least effect in increasing the client's bone mass, as it is a synthetic form of vitamin D that helps the body absorb calcium and phosphorus, which are essential for bone health. Calcitriol also regulates the bone remodeling and prevents the bone resorption.
Choice B reason: Calcium (Caltrate) with Vitamin D (Caltria) is not the medication that will have the least effect in increasing the client's bone mass, as it is a combination of calcium and vitamin D that works synergistically to enhance the bone density and strength. Calcium is the main mineral component of the bone, and vitamin D helps the body absorb calcium and phosphorus.
Choice C reason: Alendronate (Fosamax) is not the medication that will have the least effect in increasing the client's bone mass, as it is a bisphosphonate that inhibits the activity of osteoclasts, which are the cells that break down the bone. Alendronate reduces the bone loss and increases the bone mass, and it is used to treat and prevent osteoporosis.
Choice D reason: Calcium (Caltrate) without Vitamin D (Calcio) is the medication that will have the least effect in increasing the client's bone mass, as it is a calcium supplement that does not contain vitamin D, which is necessary for the calcium absorption and utilization. Calcium alone may not be sufficient to prevent or treat osteoporosis, and it may also cause side effects such as constipation, kidney stones, or hypercalcemia.
Choice E reason: None of the above is not a correct choice, as there is one option that matches the medication that will have the least effect in increasing the client's bone mass.
Correct Answer is B
Explanation
Choice A reason: Pain management is an important goal for a client with osteoarthritis, but it is not the only one. The question asks for what goals the nurse should include, not what is the most essential or urgent goal.
Choice B reason: Improvement of joint mobility is a correct goal for a client with osteoarthritis, as it helps to prevent stiffness, contractures, and deformities of the affected joints. It also improves the client's function, quality of life, and independence.
Choice C reason: Client will recover from osteoarthritis within 6 months is not a realistic or attainable goal, as osteoarthritis is a chronic and progressive condition that has no cure. The nurse should focus on managing the symptoms and preventing complications, not on curing the disease.
Choice D reason: Weight loss promotion is a relevant goal for a client with osteoarthritis, especially if the client is obese, as it helps to reduce the stress and pressure on the weight-bearing joints. However, it is not a specific or measurable goal, as it does not indicate how much weight the client should lose or how the nurse will monitor the progress.
Choice E reason: The client will deny symptoms of osteoarthritis is not a desirable or appropriate goal, as it implies that the client is not honest or aware of their condition. The nurse should encourage the client to report any symptoms or changes in their joints, as it helps to assess the effectiveness of the treatment and to adjust the plan of care accordingly.
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