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 D

Explanation

Choice A reason: Males with a cardiac history between the ages of 30 and 40 years old are not the most at risk for developing osteoporosis, as they have several protective factors, such as their gender, age, and hormone levels. Males have higher peak bone mass and lower bone loss rate than females, and they do not experience the rapid decline of estrogen that occurs after menopause. Cardiac history may affect the bone health indirectly, by limiting the physical activity or affecting the calcium absorption, but it is not a major risk factor.

Choice B reason: Females with a history of diabetes and are between the ages of 20 and 30 years old are not the most at risk for developing osteoporosis, as they have some protective factors, such as their age and hormone levels. Females in their reproductive years have higher estrogen levels than post-menopausal females, which helps to preserve the bone density and prevent the bone resorption. Diabetes may increase the risk of osteoporosis, by affecting the insulin, glucose, and inflammatory pathways, but it is not a definitive risk factor.

Choice C reason: Males who have had a previous fracture are not the most at risk for developing osteoporosis, as they have some protective factors, such as their gender and hormone levels. Males have higher peak bone mass and lower bone loss rate than females, and they do not experience the rapid decline of estrogen that occurs after menopause. A previous fracture may indicate a low bone density or a high fall risk, but it is not a conclusive risk factor.

Choice D reason: Females who have a history of estrogen deficiency and are post-menopausal are the most at risk for developing osteoporosis, as they have several risk factors, such as their gender, age, and hormone levels. Females have lower peak bone mass and higher bone loss rate than males, and they experience a significant drop of estrogen after menopause, which leads to increased bone resorption and decreased bone formation. Estrogen deficiency may also cause other symptoms, such as hot flashes, mood swings, or vaginal dryness, which may affect the quality of life and the bone health.

A. Include an average daily intake of 300 mg of calcium B. Walk 20-30 minutes three days a week C. Engage in isometric exercise 20-30 minutes weekly D. Include adequate intake of vitamin E E. None of the above

Correct Answer is E

Explanation

Choice A reason: Including an average daily intake of 300 mg of calcium is not a sufficient measure to prevent osteoporosis, as it is below the recommended dietary allowance (RDA) for calcium, which is 1000 mg for adults aged 19-50 years, and 1200 mg for adults aged 51 years and older. Calcium is an essential mineral for bone health, as it helps to build and maintain the bone density and strength.

Choice B reason: Walking 20-30 minutes three days a week is not an optimal measure to prevent osteoporosis, as it is below the recommended physical activity guidelines, which suggest at least 150 minutes of moderate-intensity aerobic exercise per week, and at least two sessions of muscle-strengthening activities per week. Physical activity is beneficial for bone health, as it stimulates the bone formation and reduces the bone loss.

Choice C reason: Engaging in isometric exercise 20-30 minutes weekly is not an effective measure to prevent osteoporosis, as it is not the best type of exercise for bone health, and it is not performed frequently enough. Isometric exercise is a form of exercise that involves contracting the muscles without moving the joints, such as holding a plank or a wall sit. Isometric exercise does not provide enough mechanical stress or load to the bones, which is needed to stimulate the bone remodeling and growth.

Choice D reason: Including adequate intake of vitamin E is not a relevant measure to prevent osteoporosis, as it is not a major nutrient for bone health, and it has no direct effect on the bone metabolism. Vitamin E is an antioxidant that helps to protect the cells from oxidative stress and inflammation, which may have some indirect benefits for the bone health, but it is not a key factor. Vitamin E is also not a common deficiency, and it can be obtained from various foods, such as vegetable oils, nuts, seeds, and green leafy vegetables.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a group of clients. Which client is most at risk for developing osteoporosis?

Correct Answer is D

Explanation

Which should the nurse include when instructing a client on the prevention of osteoporosis?

Correct Answer is E

Explanation

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

The nursing care plan for a client in traction includes regular assessments for venous thromboembolism. When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

A nurse is providing discharge education to a client who is going home with a cast on his leg. What teaching point would be appropriate for the nurse to emphasize in the teaching session?

A client with severe osteoarthritis has been treated with total hip replacement. Which intervention will the nurse implement to help protect against the risk for deep venous thrombosis (DVT)?

A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having shingles. What presentation is most consistent with this diagnosis?

A client has been diagnosed with herpes zoster present on the upper right side of the torso, extending around to the client's back. Which client statement indicates the need for further teaching regarding this diagnosis?

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?

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?