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 E
Explanation
Choice A reason: Increased circulation of the calf is not a sign or symptom of DVT, but a normal finding of the blood flow in the leg. It can be assessed by palpating the pulses, checking the capillary refill, or observing the skin color and temperature.
Choice B reason: Pale-appearing calf is not a sign or symptom of DVT, but a sign of arterial insufficiency or ischemia. It indicates the reduced blood supply and oxygen delivery to the tissues, which can cause pain, numbness, or coldness of the leg.
Choice C reason: Increased warmth in the calf is not a specific sign or symptom of DVT, but a possible sign of inflammation or infection. It may be accompanied by redness, swelling, or fever, which can indicate a local or systemic inflammatory response.
Choice D reason: Loss of sensation to the calf is not a sign or symptom of DVT, but a sign of nerve damage or compression. It may be caused by trauma, injury, diabetes, or other conditions that affect the peripheral nervous system.
Choice E reason: Swelling and tenderness of the calf is a common sign or symptom of DVT, as it indicates the presence of a blood clot in the deep veins of the leg. It may also cause pain, cramping, or heaviness of the leg, which can worsen with movement or standing.
Correct Answer is C
Explanation
Choice A reason: Administering pain medication as ordered is not the best action, as it does not address the cause of the new onset of pain. The nurse should first assess the client and the surgical site to rule out any complications or problems that may require immediate intervention.
Choice B reason: Assessing the client for signs and symptoms of systemic infection is not the best action, as it is not the most likely cause of the new onset of pain. Systemic infection would manifest with fever, chills, malaise, or leukocytosis, which are not mentioned in the scenario. The nurse should focus on the local signs and symptoms of the surgical site and the affected extremity.
Choice C reason: Assessing the surgical site and the affected extremity is the best action, as it allows the nurse to identify any potential complications or problems that may explain the new onset of pain. The nurse should look for signs of infection, inflammation, bleeding, hematoma, or dislocation of the hip prosthesis, such as redness, swelling, warmth, drainage, bruising, or deformity.
Choice D reason: Reassuring the client that pain is a direct result of increased activity is not the best action, as it may dismiss the client's concern and delay the detection of any serious complications or problems. The nurse should not assume that the pain is normal or expected, but rather investigate the cause and severity of the pain.
Choice E reason: Notifying the surgeon immediately is not the best action, as it is premature and unnecessary without first assessing the client and the surgical site. The nurse should gather relevant data and information before contacting the surgeon, unless there is an obvious or urgent problem that requires immediate attention.
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